Complaint Investigation Report

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.