complaint·August 7, 2025

On 4/25/25, LPA conducted interview with one responsible party over the phone. On 6/4/25, LPA conducted a collateral visit and interviewed an additional resident. On this same day, LPA interviewed Resident #8 (R8)’s responsible party over the phone. On 6/6/25 and 7/3/25, LPA contacted PFD Fire Captain to ask additional questions. On 6/20/25, LPA interviewed R1’s responsible party for additional information. On 7/8/25, LPA interviewed 3 staff for additional information. 7/15/25, LPA reviewed Eaton fire status reports on the California Fire website. The investigation revealed the following: Regarding allegation: Staff did not evacuate resident during mandatory evacuation. It is alleged that a resident was not evacuated by staff during a fire evacuation. A timeline of the events was established from interviews conducted with facility staff, residents, responsible parties, and fire personnel. On 1/7/25 at approximately 6:30pm, staff observed the fire at the mountain range near the facility. Business Coordinator met with staff to discuss and coordinate evacuation per their emergency disaster plan. Between 7:00pm – 7:30pm, staff began the evacuation process by transferring residents from each floor into the lobby of the building. Staff then awaited instructions from the fire department to evacuate the building. At approximately 8:30pm, staff was instructed by the fire department to evacuate the building. Per review of Fire Department Status Reports the area or zone where the facility was located received evacuation orders on 1/7/25 at 7:27pm. Interviews with staff revealed that upon observation of the fire, staff began calling family members to notify them of the situation and indicated they could pick up their loved one if possible. Staff observed the ambers closer to the facility between 7:00pm – 7:30pm and began knocking on residents’ doors. Staff began assisting residents down the stairs and additional staff not on duty at the time arrived to assist. At approximately 8:30pm, fire department arrived, and staff began to assist residents out of the building. Four of the staff interviewed indicated that between 8:45pm and 9:15pm they attempted to enter the facility again to continue to evacuate residents. However, staff was instructed by the fire department to not enter the facility. Interviews conducted with residents revealed some had been assisted by a staff member to evacuate the building. Some residents also reported that a family member picked them up before the evacuation took place. R1 stated that at approximately 6:00pm a caregiver asked R1 to wait in the room. Per R1, no one returned and was evacuated out of the building by a family member. Another resident, R8 stated to have been evacuated by 2 gentlemen, who R8 was unable to identify as they didn’t appear to be staff members. Interviews conducted with residents’ responsible parties revealed a family member stated to have entered the facility to assist R1 out of the building. R8’s responsible parties were aware of the fire but stated that they were not searching for R8 during the fire. (CONTINUED ON LIC 9099C) Interview conducted with PFD Fire Captain revealed facility staff, Pasadena Police Department, and fire department had collaborated to evacuate the residents on 1/7/25. Per Fire Captain, their department received a request from R8’s responsible party through Pasadena’s Police Department to search for R8 in room #326. The fire department evacuated R8 from room #326 and was the last resident to be evacuated from the building. Based on interviews conducted and records reviewed, it was confirmed that at least one resident was left in their room and had to be evacuated by the fire department. Therefore, the preponderance of evidence standard has been met and the allegation is found to be substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.