complaint·May 22, 2025

Interview with ED indicated that there was a small fire in the laundry room in the Memory Care Unit (MCU) on February 1, 2025 caused by a dryer in the laundry room. ED stated that staff were supposed to only evacuate residents in the MCU during fire on February 1, 2025, while some residents with oxygen were to shelter in place with care staff supervision. ED stated that fire department was contacted via the alarms and arrived promptly to address the fire. ED stated that the fire was put out when the sprinkler system was activated. LPA received an incident report from Sacramento Metropolitan Fire indicating that a fire took place on the premises February 1, 2025. Fire alarm activated at 5:56 AM and fire fighters arrived at the facility at 6:02 AM. Last unit was cleared at 7:29 AM. Incident type was "fires in structure other than building." Incident resulted in zero (0) injuries or deaths. Fire fighters reported light smoke condition in the hallway with occupants evacuating. Officer reported assisting with occupant evacuation on the second floor. Fire was contained to the laundry room in the clothes dryer and smoke was being exhausted to the exterior. Rooms 106-122 were uninhabitable due to smoke and/or water/smoke impacts. Engineer shut off and drained sprinkler system. Officer replaced the open sprinkler head and recharged the sprinkler system. Report indicated the origin of the fire to be the laundry room contained to a commercial clothes dryer due to a large lint trap. Interviews with staff members S1, S2, and S3 indicated that they do not feel adequately trained on emergency evacuation protocols. S1 stated that they were at the facility on February 1, 2025 during the fire and didn't feel properly trained on how to address a fire at the facility. S1 stated that they were not properly trained on getting wheelchair bound residents evacuated. S1 stated that the fire department was contacted when the fire alarms went off. S1 stated that they were already evacuating residents due to the smoke and got everyone out in 20 minutes at the most. S1 stated that more than half of the residents were evacuated when the fire department arrived. S1 stated that half the top floor was not evacuated, including room 237, and room 225 to room 231. S1 stated that no one had told staff not to evacuate the second floor. S1 stated that a few residents downstairs were not evacuated, including bed bound residents who needed hoyer lift assistance. S2 stated that they were at the facility during fire on February 1, 2025. S2 stated that they have worked at the facility for two (2) and a half years and has only participated in one quarterly drill. S2 stated that they were evacuating residents on the second floor and only 85 to 90 percent of the second floor was evacuated. S2 stated that they didn't feel prepared to handle the emergency. S3 indicated that they have never received Disaster and Emergency Plan training and have not participated in a quarterly drill. ** Report continued on 9099-C ** LPA reviewed facility's Plan of Operation maintained at Sacramento North Regional Office. LPA observed Operations Policy revised January 1, 2019 indicated the following: "Disaster and Emergency Plan...All staff will receive training on the Disaster and Emergency Plan upon hire and annually thereafter. The training will include staff responsibilities during an emergency or disaster." No objectives and content for Disaster and Emergency Plan training was indicated in Operations Policy. LPA observed training documentation for staff members S3, S4, S5, and S6. LPA observed that staff received "Fire Safety" training via Relias Learning upon hire and annually. LPA observed the course objectives for the Fire Safety training in Relias Learning, but could not verify if Fire Safety training met the requirements indicated in the Plan of Operation for Disaster and Emergency Plan training. LPA observed documentation for an annual review of the facility's Emergency and Disaster Plan conducted for the years of 2021, 2022, 2023, and 2024. LPA observed that documentation indicated that the Executive Director conducted the review of the plan with existing employees for the years of 2021 and 2022. Documentation did not include a list of the employees who participated in the review and was not documented in accordance with Title 22 regulations regarding personnel training. LPA observed that the documentation for the annual review of the Emergency and Disaster for 2023 and 2024 did not indicate that the plan was reviewed with existing employees. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.