|On October 8 and 9, 2017, the Santa Rosa area sustained widespread wildfires, forcing evacuations of multiple residential care facilities. On October 26, 2017, the Department initiated a complaint investigation into an allegation that facility staff failed to evacuate residents during the wildfire and left the facility while some residents were still inside the facility. |
The Department conducted on-site visits, interviewed 10 staff, 10 residents, first responders, City officials, family members, and other witnesses. The Department reviewed the Santa Rosa Police Department (SRPD) police reports, SRPD body camera footage, resident records, the facility’s Plan of Operation, and the facility’s Disaster Planning policies, and procedures dated February 16, 2017.
Per correspondence the Department received on November 10, 2017 from the Vice President of Quality Assurance and Regulatory Affairs, all 25 of the residents in the memory care portion of the building are considered non-ambulatory, since they cannot exit unassisted in the event of an emergency. The “memory care section” is the residential area of the building that houses residents with a diagnosis of dementia. According to the facility’s floor plan, the second floor houses 37 assisted living residents. Of the 37 residents in assisted living, there were 22 residents who were non-ambulatory per S15. Based on interviews, the power went on and off during the night of the fire and therefore, residents who required assistance evacuating, or were non-ambulatory, had to evacuate via the stairs instead of the elevator. Interviews conducted by the Department and review of records indicated that four staff (S5, S7, S8, and S9) were present during the night shift, but were unsure of the facility’s Emergency Evacuation Procedures. Although staff assisted with some portions of the evacuations, they did not ensure that all residents were evacuated.
The Department conducted a review of the Villa Capri file, which contained the Oakmont “Disaster and Emergency Manual for Assisted Living and Residential Care Communities.” During an interview, S15 indicated via correspondence on October 16, 2017, that the Disaster and Emergency Manual contained their evacuation procedures.
Continued on LIC9099C...