Complaint Investigation Report

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.