Two senior care facilities in Altadena and Pasadena failed to follow emergency protocols and improperly handled the evacuations of some residents during the devastating Eaton fire early this year, state investigators allege in reports recently reviewed by the Southern California News Group.
The two facilities, MonteCedro in Altadena and the Terraces at Park Marino in Pasadena, were investigated and cited by the California Department of Social Services following complaints that seniors had not been evacuated according to procedure. All residents referenced in the investigations, which were conducted over the summer, were ultimately evacuated safely.
The department found allegations that both senior care facilities failed to properly follow evacuation procedures to be substantiated. The Department of Social Services oversees licensing and monitoring of residential senior facilities in California. Both facilities are appealing the citations from the department.
The raging, wind-whipped Eaton fire, the cause of which is still under investigation, damaged or destroyed more than 9,000 structures and killed 19 people in January.
At MonteCedro, the state investigation described two residents remaining at the facility after others had been evacuated to the Pasadena Convention Center. A roll call at the convention center on the morning of Jan. 8 revealed two people were missing and facility staff notified the authorities.
One resident was outside walking their dog and the other was inside the facility.
The forgotten woman inside MonteCedro originally came to public light at the end of January when the Los Angeles County Sheriff’s Department released bodycam footage of two deputies finding the 100-year-old, who told them she was deaf and had been charging her hearing aids, rendering her unable to hear anything as the facility was being evacuated.
“I’ve been trying to find a way out,” she said to the deputies.
“No one was able to explain how” one resident was left in a room and the other was outside walking their dog, or how long the resident was outside or where they were when a shelter-in-place directive was ordered, the report says.
The DSS report investigating MonteCedro found that the facility did not train all staff in emergency procedures and that two residents were left behind in the midst of the evacuation as the Eaton fire grew. The residents were ultimately located by sheriff’s deputies.
Administrative personnel and managers at MonteCedro were the only staff who received emergency disaster training. Management worked during the day and had left by the time winds picked up, according to the DSS report. The executive director called the facility around 11:30 p.m. on Jan. 7 to issue a shelter-in-place order.
The facility’s protocol for disasters dictated that “designated staff,” which was the facility’s executive director, should stay physically at the site during disasters. The executive director had additional responsibilities during a disaster, according to the plan, including using an emergency recall list to get additional staff to the facility. When asked for the recall list of staff name and contact information amidst the Eaton fire, the director said there was not one, according to the DSS report. No additional staff were called in. The report notes that the executive director had left the facility around 10:30 p.m. on Jan. 7 and said to call if anything was needed.
During interviews, the DSS learned that night shift nurses allegedly were meant to spearhead facility operations when the executive director was not there. The nurse on night shift that evening had been brought in from an agency because of staffing shortages at the facility and was not advised of the emergency evacuation procedures.
“When the wind worsened and fires started in the area, the [executive director] and other Executive members and managers were communicating via a group chat and were waiting to receive a mandatory evacuation order from the Sheriff Department. Interim staff did not receive any instructions to walk through the facility, check the residents or bring them down to the assembly area to prepare in case an evacuation was needed,” according to DSS’ report.
Staff assigned to emergency duties were not physically at the facility until after 5 a.m. the next day, Jan. 8, according to the report.
That is around when the evacuation to the Pasadena Convention Center took place, after staff members’ various attempts to contact the sheriff’s department were successful around 3 a.m. and the department was able to provide buses and assistance to the facility later that morning.
“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 (sic) at this time,” the state report reads.
MonteCedro is appealing the citations from DSS. The facility was cited for not meeting requirements to have an emergency plan that confirms the location of all residents during an emergency. The plan of corrections listed by DSS outlines further training for residents and staff regarding emergency protocol, with proof and content outlines submitted to the department.
An online statement from MonteCedro indicates a new executive director was brought on in August 2025. MonteCedro could not be immediately reached for comment.
At The Terraces at Park Marino, the social services investigation report says a resident was left behind, eventually evacuated by Pasadena Fire Department personnel rather than facility staff.
According to the report, the staff at The Terraces had a meeting on the evening of Jan. 7 to discuss the Eaton fire, which was burning on a mountain range near the facility. From 7 to 7:30 p.m., the evacuation process began with staff moving residents to the lobby from each floor.
Staff had called family members of residents to tell them they could pick them up if possible, the report says.
When embers were spotted near the facility, staff went door to door, helped residents down the stairs and were joined by additional staff that had not been initially on duty. The fire department arrived at the facility and staff worked to get residents out of the building as the fire department issued an evacuation order, the report states.
Between 8:45 p.m. and 9:15 p.m. again, staff said they tried to go back into the building to continue evacuations, but were told to stay outside by the fire department, according to the report.
In interviews with DSS, some residents reported being evacuated by staff and some said they were picked up by family before the evacuation started.
One resident told the department they were told by a caregiver to wait in their room, but one one came back and they were eventually evacuated by their family member, which the resident’s responsible parties confirmed to DSS. Further information about this resident was not detailed in the report.
Another resident, referred to in the report as Resident/R 8, said they were evacuated by two men they could not identify. The two men did not appear to be staff members and the resident’s responsible parties said they knew about the fire, but did not go searching for the resident during it.
The report found that as Pasadena firefighters, police and the facility staff evacuated the facility, the fire department received a request from the resident’s responsible party, through the police department, to search for the resident. They provided the resident’s room number, where fire personnel located and evacuated the resident– the last person to be evacuated, according to the department’s report.
“Based on interviews conducted and records reviewed, it was confirmed that at least one resident was left in their room and had to be evacuated by the fire department. Therefore, the preponderance of evidence standard has been met and the allegation is found to be substantiated,” the report says.
Based on the report, a previous investigation found the allegation to be unsubstantiated, but the revised report “supersedes” that and finds the allegation substantive.
“The conclusion of the second report makes no sense,” said Adam Khalifa, CEO of The Terraces at Park Marino in a statement. “Resident 8 was never abandoned—she was rescued by firefighters after our staff alerted them that she was unable to evacuate from the third floor because she requires a wheelchair and the elevators were out. The record is clear: our team worked in concert with the first responders to perform a mass evacuation under very difficult circumstances.”
The Terraces at Park Marino were ultimately destroyed in the Eaton fire. It is expected to reopen in 2027, according to the facility.
The Terraces is also appealing the citation received from the department. The citation states that the facility did not meet the requirement to provide care and supervision by competent staff that meets their needs, evidenced by the evacuation of a resident by the fire department rather than facility staff.
The facility is appealing the citation based on the facts of the situation and the procedural handling of the appeal. The Terraces’ appeal states that an initial report, which DSS superseded with a second report, was replaced entirely, which the facility says “undermines the integrity of public recordkeeping obligations.” The facility also takes issue with what they say is a shift in topic in the second report, from focus on one resident in the first complaint report to a different resident in the second, a resident the Terraces said never filed a complaint.
“Instead, it omits any discussion of [the resident allegedly evacuated by family] and leaves the original complaint unresolved.”
In the previous investigation, DSS found the claims that a resident had been evacuated by a family member to be unsubstantiated, writing that it may have happened, but there was not a preponderance of evidence to support that the claim did or did not happen. A copy of the initial complaint investigation report regarding the Terraces was shared by the facility with the Southern California News Group.
“This entire controversy stems from a complaint filed by a resident’s family member, who falsely claimed his mother was left behind and that he rescued her himself from our building around 9:15 p.m. during the Eaton Fire,” Khalifa said. “The state’s first report demonstrated that was impossible. It showed that at 8:30 p.m. the Pasadena Fire Department had full control of the building, and our staff safely evacuated nearly 100 residents. Firefighters then barred staff from re-entering after 8:45 p.m. By 9:15 p.m., the building was fully engulfed in flames. The second report omitted those facts and failed to reach any finding about the original complaint. That’s why we’re calling on the State to republish its original report—so the public record reflects the facts and clears our team of these false allegations.”
The second investigation, “shifts focus to [the other resident evacuated by fire officials]– who never filed a complaint and whose family has never alleged any wrongdoing by the Terraces,” a Terraces appeal reads. The appeal notes that the Pasadena Fire Department had told staff to not to re-enter the building, at which point staff told the department the resident still needed to be evacuated. Fire personnel confirmed they would evacuate the resident and clear all floors, an appeal says.
“The expectation that the Terraces should have evacuated R8 after PFD assumed control is incompatible with both the law and operational reality,” an appeal argues.
The Department of Social Services could not be reached for additional comment.