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Journey & # 39; s Endeavor's mobile home park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa, California on Monday, October 9, 2017.
Journey & # 39; s Endeavor's mobile home park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa, California on Monday, October 9, 2017.
Photo: Gabrielle Lurie / The Chronicle
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Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa, California on Wednesday, October 11, 2017.
Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa, California on Wednesday, October 11, 2017.
Photo: Paul Chinn, The Chronicle
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Petaluma firefighter Greg Taylor takes a break from a big house that burned in The Ranch Ranch estate in Sonoma, California on Saturday, October 14, 2017.
Petaluma firefighter Greg Taylor takes a break from a big house that burned in The Ranch Ranch estate in Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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Firefighters from Santa Cruz, Josiah Gist and Ian Adams carry a hose over the pool of a large house that burned in the Ranch estate in Sonoma, California on Saturday, October 14, 2017.
Firefighters from Santa Cruz, Josiah Gist and Ian Adams carry a hose over the pool of a large house that burned in the Ranch estate in Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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The chimney is all that remains standing in a big house that burned in the Ranch estate in Sonoma, California on Saturday, October 14, 2017.
The chimney is all that remains standing in a big house that burned in the Ranch estate in Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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Three firefighters are watching a large house burned at The Ranch in Sonoma, Calif., On Saturday, October 14, 2017.
Three firefighters are watching a large house burned at The Ranch in Sonoma, Calif., On Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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A firefighter crosses what remains of a large house that burned in The Ranch Estate in Sonoma, California on Saturday, October 14, 2017.
A firefighter crosses what remains of a large house that burned in The Ranch Estate in Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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Josiah Gist (right) joins firefighters from Santa Cruz using pool water to fight fires in a large house that burned in the Ranch estate in Sonoma, California on Saturday, October 14th 2017.
Josiah Gist (right) joins firefighters from Santa Cruz using pool water to fight fires in a large house that burned in the Ranch estate in Sonoma, California on Saturday, October 14th 2017.
Photo: Scott Strazzante, The Chronicle
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Smoking in the hills east of Sonoma, California on Saturday, October 14, 2017.
Smoking in the hills east of Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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The sun sets on Sonoma, California on Saturday, October 14, 2017.
The sun sets on Sonoma, California on Saturday, October 14, 2017.
Photo: Scott Strazzante, The Chronicle
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Search and Rescue personnel search for human remains in the Journey & # 39; s Endless Mobile Homes Park following the damage caused by the Tubbs fire on October 13, 2017 in Santa Rosa. Twenty-four people died in forest fires that burned tens of thousands of acres and destroyed more than 3,500 homes and businesses in several counties in northern California.
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Search and Rescue personnel search for human remains in the Journey & # 39; s Endless Mobile Homes Park following the damage caused by the Tubbs fire on October 13, 2017 in Santa Rosa. Twenty-four people died in forest fires
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Photo: Elijah New Zealand / Getty Images
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A CalFire firefighter uses a hand tool while he is monitoring a firefighting operation while fighting the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty people died in fires that burned tens of thousands of acres and destroyed more than 3,500 homes and businesses in several northern California counties. Less
A CalFire firefighter uses a hand tool while monitoring a firing operation while fighting the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in forest fires … more
Photo: Justin Sullivan, Getty Images
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On October 12, 2017, near Calistoga, California, a stairwell burns while the house burns during the Tubbs fire. At least thirty-one people have died in fires that have burned tens of thousands of acre counties. Less
On October 12, 2017, near Calistoga, California, a stairwell burns while the house burns during the Tubbs fire. At least thirty-one people died in forest fires that burned tens of thousands of acres and … more
Photo: Justin Sullivan, Getty Images
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Firefighters at CalFire are monitoring a firing operation while fighting the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people have died in fires that have burned tens of thousands of hectares of California counties. Less
CalFire firefighters are overseeing a firing operation as they fight the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in forest fires that burned people … more
Photo: Justin Sullivan, Getty Images
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Firefighters are attempting to extinguish a house fire during the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people have died in fires that have burned tens of thousands of acres and destroyed more than 3,500 homes and businesses counties. Less
Firefighters are trying to put out a fire during the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in forest fires that burned tens of thousands of acres and … more
Photo: Justin Sullivan, Getty Images
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CalFire firefighters are monitoring a firing operation while they are fighting the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in fires that burned tens of thousands of California county counties. Less
CalFire firefighters are monitoring a firefighting operation as they fight the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in forest fires that burned tens of thousands of acres … more
Photo: Justin Sullivan, Getty Images
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A CalFire firefighter uses a watering hose to monitor hot spots during a shooting operation on October 12, 2017, near Calistoga, California. At least thirty-one people died in fires that destroyed tens of thousands of acres. 3,500 homes and businesses in several counties in northern California. Less
A CalFire firefighter uses a hose to monitor hot spots during a shooting operation during the Tubbs Fire Fight on October 12, 2017 near Calistoga, California. At least thirty-one people died in … more
Photo: Justin Sullivan, Getty Images
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Firefighters are trying to extirpate a house fire during the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people have died in fires that have burned tens of thousands of acre counties. Less
Firefighters are trying to extirpate a house fire during the Tubbs fire on October 12, 2017 near Calistoga, California. At least thirty-one people died in forest fires that burned tens of thousands of acres and … more
Photo: Justin Sullivan, Getty Images
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Jimmie Allen, raised a piece of metal that had melted during the fire and had solidified next to his car at Coffey Park on Wednesday, October 11, 2017 in Napa. Allen's home in Coffey Park burned in the Tubbs fire. Less
Jimmie Allen, raised a piece of metal that had melted during the fire and had solidified next to his car at Coffey Park on Wednesday, October 11, 2017 in Napa. The Allen House at Coffey Park burned in the Tubbs … more
Photo: Lea Suzuki, The Chronicle
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Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa on Wednesday, October 11, 2017.
Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa on Wednesday, October 11, 2017.
Photo: Paul Chinn, The Chronicle
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A BART police officer, Trabanino, is holding a fire control post at Tubbs on the Bennett Valley Road. in Santa Rosa. Thursday, October 12, 2017. He told an evacuee that the neighborhood is still closed to residents.
A BART police officer, Trabanino, is holding a fire control post at Tubbs on the Bennett Valley Road. in Santa Rosa. Thursday, October 12, 2017. He told an evacuee that the neighborhood is still closed to residents.
Photo: Noah Berger, special for the chronicle
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The leveled homes of Tubbs fire surround the Coffey Park neighborhood in Santa Rosa on Wednesday, October 11, 2017.
The leveled homes of Tubbs fire surround the Coffey Park neighborhood in Santa Rosa on Wednesday, October 11, 2017.
Photo: Noah Berger, special for the chronicle
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Rubble scratches the inside of a K-mart store burned by the Tubbs fire in Santa Rosa on Wednesday, October 11, 2017.
Rubble scratches the inside of a K-mart store burned by the Tubbs fire in Santa Rosa on Wednesday, October 11, 2017.
Photo: Noah Berger, special for the chronicle
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Massive flames in the Tubbs The fire consumes thick grasses and tall trees near Santa Rosa on Wednesday, October 11, 2017.
Massive flames in the Tubbs The fire consumes thick grasses and tall trees near Santa Rosa on Wednesday, October 11, 2017.
Photo: Paul Chinn, The Chronicle
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An elementary school room at St. Rose School is damaged by the Tubbs fire in Santa Rosa on Wednesday, October 11, 2017.
An elementary school room at St. Rose School is damaged by the Tubbs fire in Santa Rosa on Wednesday, October 11, 2017.
Photo: Alex Washburn, The Chronicle
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Karen Balestieri and Heidi Facciano (from left to right) marvel at a live koi fish pond that survived the Tubbs fire in the neighborhood called "Old Fountain" in Santa Rosa on Wednesday, October 11, 2017 less
Karen Balestieri and Heidi Facciano (from left to right) marvel at a live koi fish pond that survived the Tubbs fire in the neighborhood that the locals called "old ice wells" in Santa Rosa … more
Photo: Alex Washburn, The Chronicle
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A helicopter drops a drop of water on the flames of the Tubbs fire on a hill as it approaches the Bennett Valley Road homes on Wednesday, October 11, 2017 in Santa Rosa.
A helicopter drops a drop of water on the flames of the Tubbs fire on a hill as it approaches the Bennett Valley Road homes on Wednesday, October 11, 2017 in Santa Rosa.
Photo: Lea Suzuki, The Chronicle
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Brian Kitchen (left) and his son Tarreyl Kitchen (right) wash their hands in a pool after searching the remains of their home after it was destroyed in the Tubbs fire in the Coffey Park neighborhood in Santa Rosa Tuesday, October 10, 2017. less
Brian Kitchen (left) and his son, Tarreyl Kitchen (right) wash their hands in a pool after sifting through the remains of their home after it was destroyed in the Tubbs fire in the Coffey neighborhood Park.
Photo: Gabrielle Lurie, the chronicle
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A wall stands in a Chanterelle Circle house destroyed by the Tubbs fire in the Fountaingrove district of Santa Rosa on Tuesday, October 10, 2017.
A wall stands in a Chanterelle Circle house destroyed by the Tubbs fire in the Fountaingrove district of Santa Rosa on Tuesday, October 10, 2017.
Photo: Noah Berger, special for the chronicle
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Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa on Wednesday, October 11, 2017.
Smoke from the Tubbs The fire is rising in the air as the fire storm continues to burn near Santa Rosa on Wednesday, October 11, 2017.
Photo: Paul Chinn, The Chronicle
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Firefighters are working to contain the Tubbs fire at the Bicentennial Way Overlook apartment complex in Santa Rosa on Monday, October 9, 2017.
Firefighters are working to contain the Tubbs fire at the Bicentennial Way Overlook apartment complex in Santa Rosa on Monday, October 9, 2017.
Photo: Gabrielle Lurie / The Chronicle
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A resident rushes to save his home while an uncontrolled wildfire spreads in the area on October 9, 2017 in Glen Ellen, California.
A resident rushes to save his home while an uncontrolled wildfire spreads in the area on October 9, 2017 in Glen Ellen, California.
Photo: Justin Sullivan, Getty Images
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Firefighter Derick O'Leary, left, and Danny Dortch help fight fires on Baird Road in Santa Rosa, California. Monday, October 9, 2017.
Firefighter Derick O'Leary, left, and Danny Dortch help fight fires on Baird Road in Santa Rosa, California. Monday, October 9, 2017.
Photo: Mason Trinca / Special At The Chronicle
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A laundromat inside Journey & # 39; s Endeavor's mobile home park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa, California on Monday, October 9, 2017.
A laundromat inside Journey & # 39; s Endeavor's mobile home park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa, California on Monday, October 9, 2017.
Photo: Gabrielle Lurie, the chronicle
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A wall stands on a house in Chanterelle Circle destroyed by the Tubbs fire in the Fountaingrove neighborhood of Santa Rosa, California on Tuesday, October 10, 2017.
A wall stands on a house in Chanterelle Circle destroyed by the Tubbs fire in the Fountaingrove neighborhood of Santa Rosa, California on Tuesday, October 10, 2017.
Photo: Noah Berger / Special at the chronicle
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Steph Gediman (left) comforts Brandi Burns in front of the destruction of Burns at the Tubbs fire site in Santa Rosa on Monday, October 9, 2017. Massive fires ravaged Napa and Sonoma counties Monday morning, destroying Hundreds of homes and businesses on Monday, October 9, 2017
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Steph Gediman (left) comforts Brandi Burns in front of Burns' destroyed at the Tubbs fire place in Santa Rosa on Monday, October 9, 2017. Massive fires ravaged early Napa and Sonoma counties
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Photo: Michael Macor / The Chronicle
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A statue of Jesus is seen as firefighters work to contain the Tubbs fire at Cardinal Newman High School in Santa Rosa on Monday, October 9, 2017.
A statue of Jesus is seen as firefighters work to contain the Tubbs fire at Cardinal Newman High School in Santa Rosa on Monday, October 9, 2017.
Photo: Gabrielle Lurie / The Chronicle
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Neighbors rush to help save a house with their buckets of water on Baird Road in Santa Rosa on Monday, October 9, 2017.
Neighbors rush to help save a house with their buckets of water on Baird Road in Santa Rosa on Monday, October 9, 2017.
Photo: Mason Trinca / Special At The Chronicle
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A palm tree is engulfed in smoke as the Tubbs fire passes through the Journey & # 39; s End mobile home on Mendocino Avenue in Santa Rosa on Monday, October 9, 2017.
A palm tree is engulfed in smoke as the Tubbs fire passes through the Journey & # 39; s End mobile home on Mendocino Avenue in Santa Rosa on Monday, October 9, 2017.
Photo: Gabrielle Lurie / The Chronicle
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Captain Mike Harrison of Santa Rosa leads his team of firefighters in a small traffic light in the Oakmont district of Santa Rosa, California. Tuesday, October 10, 2017.
Captain Mike Harrison of Santa Rosa leads his team of firefighters in a small traffic light in the Oakmont district of Santa Rosa, California. Tuesday, October 10, 2017.
Photo: Michael Macor / The Chronicle
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The Journey & # 39; s Endless Mobile Homes Park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa on Monday, October 9, 2017.
The Journey & # 39; s Endless Mobile Homes Park burns during the Tubbs fire on Mendocino Avenue in Santa Rosa on Monday, October 9, 2017.
Photo: Gabrielle Lurie, the chronicle
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The Fountain Grove Inn hotel burns during the Tubbs fire on Fountaingrove Pkwy in Santa Rosa on Monday, October 9, 2017.
The Fountain Grove Inn hotel burns during the Tubbs fire on Fountaingrove Pkwy in Santa Rosa on Monday, October 9, 2017.
Photo: Gabrielle Lurie, the chronicle
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People watch the sunset through the smoke in the air of a fire on Mount Veeter in Napa on Tuesday, October 10, 2017.
People watch the sunset through the smoke in the air of a fire on Mount Veeter in Napa on Tuesday, October 10, 2017.
Photo: Elijah New, special to the chronicle
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Gateway to a property along WarnSprings Rd. At Glen Ellen on October 9, 2017.
Gateway to a property along WarnSprings Rd. At Glen Ellen on October 9, 2017.
Photo: Peter DaSilva / Special at the Chronicle
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Brian Kitchen (left) and his son Tarreyl Kitchen (right) wash their hands in a pool after searching the remains of their home after it was destroyed in the Tubbs fire in the Coffey Park neighborhood in Santa Rosa Tuesday, October 10, 2017.
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Brian Kitchen (left) and his son, Tarreyl Kitchen (right) wash their hands in a pool after sifting through the remains of their home after it was destroyed in the Tubbs fire in the Coffey Park neighborhood.
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Photo: Gabrielle Lurie / The Chronicle
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Police are looking for signs of Karen Aycock, a resident of Coffey Park who has been missing since the Tubbs fire in her neighborhood in Santa Rosa on Tuesday, October 10, 2017.
Police are looking for signs of Karen Aycock, a resident of Coffey Park who has been missing since the Tubbs fire in her neighborhood in Santa Rosa on Tuesday, October 10, 2017.
Photo: Noah Berger / Special at the chronicle
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Nikki Albrecht fait une pause devant la maison détruite de sa mère sur les lieux de l'incendie de Tubbs à Santa Rosa le lundi 9 octobre 2017. Des incendies massifs ont ravagé lundi les comtés de Napa et Sonoma, détruisant des centaines de maisons et d'entreprises 9, 2017
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Nikki Albrecht fait une pause devant la maison détruite de sa mère sur les lieux de l'incendie de Tubbs à Santa Rosa le lundi 9 octobre 2017. Des incendies massifs ont ravagé les comtés de Napa et de Sonoma tôt lundi,
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Photo: Michael Macor / The Chronicle
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La fumée de l'incendie de Tubbs est vue de la voie bicentenaire à Santa Rosa le lundi 9 octobre 2017.
La fumée de l'incendie de Tubbs est vue de la voie bicentenaire à Santa Rosa le lundi 9 octobre 2017.
Photo: Gabrielle Lurie, la chronique
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Les restes des maisons du quartier de Coffey Park sont vus du ciel Ă Santa Rosa le mardi 10 octobre 2017.
Les restes des maisons du quartier de Coffey Park sont vus du ciel Ă Santa Rosa le mardi 10 octobre 2017.
Photo: Elijah Nouvelage, spécial à la chronique
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Les restes des maisons du quartier de Coffey Park sont vus du ciel Ă Santa Rosa le mardi 10 octobre 2017.
Les restes des maisons du quartier de Coffey Park sont vus du ciel Ă Santa Rosa le mardi 10 octobre 2017.
Photo: Elijah Nouvelage, spécial à la chronique
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Des feux couvants sont visibles sur les vestiges de l’hôtel Hilton Sonoma Wine Country à Santa Rosa le mardi 10 octobre 2017.
Des feux couvants sont visibles sur les vestiges de l’hôtel Hilton Sonoma Wine Country à Santa Rosa le mardi 10 octobre 2017.
Photo: Elijah Nouvelage, spécial à la chronique
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L'adjoint du shérif du comté d'Alameda transporte des réservoirs d'oxygène dans l'une des salles du centre de développement de Sonoma lors d'une évacuation obligatoire alors que l'incendie de Tubbs menace la ville de Glen Ellen, en Californie, le lundi 9 octobre 2017.
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L’adjoint du shérif du comté d’Alameda transporte des réservoirs d’oxygène vers l’un des quartiers du centre de développement de Sonoma lors d’une évacuation obligatoire alors que le feu de Tubbs menace la ville de Glen Ellen, en Californie.
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Photo: Peter DaSilva, spécial à la chronique
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Maria Norris et son mari Keith ont perdu leur maison dans l'incendie, à Santa Rosa, le lundi 9 octobre 2017. Des incendies de grande ampleur ont ravagé les comtés de Napa et Sonoma lundi matin, détruisant des centaines de maisons et de commerces le 9 octobre 2017.
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Maria Norris et son mari Keith ont perdu leur maison dans l'incendie, à Santa Rosa le lundi 9 octobre 2017. Des incendies massifs ont ravagé les comtés de Napa et de Sonoma lundi matin, détruisant des centaines de maisons et
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Photo: Michael Macor / The Chronicle
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Keith Norris shows what his car destroyed in the fire looked like before the fire, in Santa Rosa on Monday Oct. 9, 2017. Massive wildfires ripped through Napa and Sonoma counties early Monday, destroying hundreds of homes and businesses on Monday October 9, 2017
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Keith Norris shows what his car destroyed in the fire looked like before the fire, in Santa Rosa on Monday Oct. 9, 2017. Massive wildfires ripped through Napa and Sonoma counties early Monday, destroying
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Photo: Michael Macor/The Chronicle
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Homeowner Phil Rush looks at the remains of his home destroyed by wildfire in Santa Rosa on Oct. 11, 2017. Rush said he and his wife and dog escaped with only their medication, a bag of dog food when flames overtook their entire neighborhood on October 9. The toll from Northern California's ranging wildfires continued to grow as officials said the fires destroyed up to 2,000 structures and killed at least 17 people.
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Homeowner Phil Rush looks at the remains of his home destroyed by wildfire in Santa Rosa on Oct. 11, 2017. Rush said he and his wife and dog escaped with only their medication, a bag of dog food when flames … more
Photo: ROBYN BECK, AFP/Getty Images
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Arilyn Edwards, 6, stands beside her bike in front of the rubble of her Santa Rosa home on Tuesday, Oct. 10, 2017. The bike, which was a gift for her 6th birthday on Oct. 6, was destroyed as fire ripped through her neighborhood on Sunday evening. Less
Arilyn Edwards, 6, stands beside her bike in front of the rubble of her Santa Rosa home on Tuesday, Oct. 10, 2017. The bike, which was a gift for her 6th birthday on Oct. 6, was destroyed as fire ripped through … more
Photo: Guy Wathen, The Chronicle
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Brian Gilman displays antique tea cups he found while digging through the rubble of his mother's home on Tuesday, Oct. 10, 2017 in Santa Rosa. "She lost everything but the clothes she was wearing, her medicine, everything else is gone except for the two cups she asked for. According to Gilman the cups are over 200 years old. less
Brian Gilman displays antique tea cups he found while digging through the rubble of his mother's home on Tuesday, Oct. 10, 2017 in Santa Rosa. "She lost everything but the clothes she was wearing, her medicine, … more
Photo: Guy Wathen, The Chronicle
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John Palmer, left, who escaped as flames surrounded his home, covers his eyes while waiting to return to his burned residence on Monday, Oct. 9, 2017, in Glen Ellen, Calif. At right is a resident who declined to be identified.
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John Palmer, left, who escaped as flames surrounded his home, covers his eyes while waiting to return to his burned residence on Monday, Oct. 9, 2017, in Glen Ellen, Calif. At right is a resident who declined
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Photo: Noah Berger/Special To The Chronicle
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Photo: Gabrielle Lurie / The Chronicle
The Journey's End mobile home park burns during a the Tubbs fire on Mendocino Avenue in Santa Rosa, Calif., on Monday, Oct. 9, 2017.
The Journey's End mobile home park burns during a the Tubbs fire on Mendocino Avenue in Santa Rosa, Calif., on Monday, Oct. 9, 2017.
Photo: Gabrielle Lurie / The Chronicle
Facilities’ staff fled, abandoned seniors during Tubbs Fire, state says
State regulators moved to revoke the licenses of two Santa Rosa senior housing facilities Thursday after finding that employees abandoned dozens of elderly and disabled residents during a confused and frantic evacuation amid the deadly Tubbs Fire last year.
Investigators with the California Department of Social Services concluded that the staffers at the Varenna and Villa Capri apartments were untrained and ill-equipped to handle evacuations, and that supervisors in both facilities left residents alone at the peak of the crisis.
Two dozen residents of Villa Capri would have died in the fire if not for the actions of family members and emergency personnel to get them out before the building went up in flames, according to a complaint filed by the department. It cites the licensed operator of the facilities, Oakmont Senior Living, as well as its management group and the executive directors of the centers, Deborah Smith and Nathan Condie.
The licenses will be revoked in 15 days unless an appeal is filed requesting a hearing before an administrative law judge.
“Based on evidence gathered during the investigations and the statements of witnesses, the department has determined that Oakmont Senior Living failed to protect the health and safety of residents at Varenna and Villa Capri,” Michael Weston, the spokesman for the California Department of Social Services, wrote in a statement. “The Department served Oakmont Senior Living with legal notice to revoke the licenses of Varenna and Villa Capri and to exclude the administrators of both facilities for life.”
Oakmont representatives denied the allegations in a statement Thursday, saying “all 418 residents were safely evacuated” and thanking families, neighbors and emergency personnel for their help.
“The night of the Tubbs fire, we voluntarily began evacuating residents after we were repeatedly unable to reach emergency authorities on clogged 911 phone lines. We never received an official evacuation order from emergency authorities,” the statement said. “Our residents and their safety have been, and always will be, our first priority.”
Oakmont officials said earlier this year that emergency personnel prevented staff from returning to the buildings to evacuate the rest of the residents.
None of the residents of the two high-end assisted-living facilities died in the fire, but the complaint describes confusion, inattention and breakdowns in communication among the managers as the fire crackled toward the building the night of Oct. 8 and early morning Oct. 9.
Smith, administrator of Villa Capri, failed to train the four staffers on duty that night in emergency and evacuation procedures, according to the complaint. They were responsible for 62 residents, 25 of whom were in the memory care unit and unable to exit the building unassisted, the report said.
The employees did not know where flashlights, batteries or keys to the facility’s vehicles were, and two of them were incapable of moving or assisting residents because they could not lift more than 10 pounds or use both hands, the document said.
One staffer searched for an hour that night, checking four rooms in the building, but could not find keys to any vehicles, the complaint said. Outside was a large bus that could have been used to evacuate all the residents, but nobody knew where to find the keys.
Sometime between 3 a.m. and 3:30 a.m., as the fire raged outside, a supervisor, who did not call 911 or notify anyone about the situation, left two untrained staffers with 30 elderly and infirm residents. They subsequently evacuated six residents in their personal vehicles, leaving 24 infirm patients alone in the building as flames approached, the complaint said.
Smith knew about the emergency at 11:30 p.m., but never made it to the facility and eventually arrived at an evacuation center at 6 a.m. the next day. The residents were saved by family members, who flagged down a police cruiser and helped their stranded relatives down from the second floor and out from behind a locked door in the lobby, the report said.
A 92-year-old woman who suffered from blindness, dementia and hearing impairments reportedly was injured with a broken hip while being rescued by a good Samaritan.
“If these family members and emergency responders had not evacuated Villa Capri residents, more than 20 residents would have perished when Villa Capri burned to the ground after all staff left the facility,” the report stated.
The situation at Varenna, where 228 residents were living, was equally chaotic, according to the report. It said Condie, the administrator, had failed to train the two health care workers and two maintenance staffers on duty that night in emergency procedures.
When Condie arrived sometime between 12:30 a.m. and 1 a.m., he was unable to articulate an evacuation plan and instead directed the staff to return the residents to their rooms, the report said. He left the facility in his car with a small number of residents at about 3:30 a.m., and did not tell the staffers where keys to a large bus owned by Varenna were located.
All the other staffers later departed, leaving the residents asleep in their rooms as the fire raged toward the facility. They were eventually evacuated by their families and friends, who reported spending hours pounding on doors,waking up and assisting residents, many using walkers and wheelchairs, to the lobby, according to the report.
When emergency responders finally arrived at 4:15 a.m., no staffers were available to identify residents or provide a list of those who were evacuated, the report said. They said they had to kick open locked doors throughout the facility to locate and alert sleeping residents.
Besides revoking the licenses of the facilities, the complaint would also ban Smith and Condie from ever again working at a care facility.
“We’re very pleased that the state of California has held Oakmont accountable and sent a very strong message that it needs to spend money on residents and not just pretty buildings,” said Kathryn Stebner, the attorney for former Villa Capri and Varenna residents, who settled a lawsuit filed on behalf of the residents Aug. 17 for an undisclosed sum.
“They said they had training and had an evacuation plan, and we found that they did not have training and they did not have an evacuation plan, and we also found that the residents were abandoned,” she said. “These people would have been dead if not for the heroic acts of family members.”
The state investigated another care facility, Fountaingrove Lodge, but no wrongdoing was found.
Peter Fimrite is a San Francisco Chronicle staff writer. Email: [email protected]. Twitter: @pfimrite