complaint·August 8, 2025

Cont. from LIC 9099-C They notified the ED that they had evacuated. At around 7:00am, after everyone arrived at the emergency shelter, the facility staff completed roll call and noted that 2 residents were not at the Pasadena Convention Center. Facility staff notified the Sheriff’s Department. They returned to the facility and conducted a sweep of the facility. This was when they located resident #1 (R1) in the hallway. While they were evacuating R1, Resident #2 (R2), was walking towards the facility from outside. R2 had no knowledge about the evacuations. They were coming back after walking their dog. Both residents were taken to the Pasadena Convention Center. No one was able to explain how R1 was left in their room and how R2 end up being outside of the facility walking their dog, it was not clear how long R2 was outside and where was R2, after ED ordered “Shelter in Place.” Interviews revealed that an annual emergency disaster training was provided only to the administrative personnel and managers. On 01/07/2025 when the wind picked up in Altadena most administrative personnel and management left the facility and went home. They worked in the morning between 7:00am-5:00pm. During the review of the facility’s Disaster Protocol Procedures, the LPM and LPA read that during an emergency, designated staff should remain at the facility physically. The designated staff was the ED (pg.1). If a disaster occurs all staff on shift are responsible for the residents. (pg. 4). The ED is responsible for notifying Community Care Licensing (CCL) of the disruption of services. ED is also responsible for arranging additional staff to report to the facility through the emergency recall list. During the initial visit, when the LPA requested the recall list from the ED, ED replied that there was no recall list available with staff’s names and phone numbers, and no staff was contacted to assist. The ED left the facility the night before and informed S1 to contact him should they need anything. Based on the information revealed during interviews and records review, it was concluded that 2 residents were left behind due to the facility’s failure to follow facility emergency evacuation procedures. Therefore, the allegation is SUBSTANTATED at this time. No health and safety issues were noted during this visit. Exit interview conducted. Deficiency issued on 9099-D. Report signed and issued. Appeal rights delivered. Cont. from LIC 9099 On 01/07/2025 from 11:00pm-7:00am there were only 5 individuals working at the facility: the Building and Safety Manager Staff #1 (S1); one security guard Staff #2 (S2), two caregivers Staff #3 (S3) and Staff #4 (S4), and one LVN Staff #5 (S5). ED, who was assigned as the emergency contact per the facility’s emergency evacuation procedures, left the facility at approximately 10:30pm. At 11:30pm they called the facility and gave an order to S1 to “Shelter in Place”. The only person who had knowledge of facility emergency evacuation procedures and was on shift was S1 who was busy securing the building, preparing water hoses, checking generators, and other parameters. Interviews also revealed that LVNs that work each shift were allegedly in charge of the facility operations in the absence of the Executive Director. However, the nurse working the night shift on 01/07/2025 and 01/08/2025, was not a facility staff. Due to staff shortages the facility brought in a nurse from an outside agency. The ED that was responsible for putting the emergency procedures into action did not inform the LVN of the emergency evacuation procedures, before they left the facility at 10:30pm. No additional instructions were given, and no arrangements were made to bring additional qualified staff who had knowledge of the facility evacuation procedures were put in place. Facility residents, except those who got the information from the news, were not notified about the high winds, possible power outage, or any other concerns. When the wind worsened and fires started in the area, the ED and other Executive members and managers were communicating via a group chat and were waiting to receive a mandatory evacuation order from the Sheriff Department. Interim, staff did not receive any instructions to walk through the facility, check the residents or bring them down to the assembly area to prepare in case an evacuation was needed. The individuals that had specific assigned emergency duties were not present in the facility and did not return to the facility until after 5:00am on the following day 01/08/2025. On 01/08/2025 at approximately 3:00am after many attempts to contact the Sheriff’s Department, S1 and S2 were able to contact the Sheriff’s Department and requested assistance to evacuate the residents in care. In total, the Sheriffs provided 6 buses, and the facility had 2 buses to transport the residents to the Pasadena Convention Center. At approximately 5:30am the evacuation started, and residents and staff were transported to the Pasadena Convention Center. Cont. on LIC9099-C