In the wake of the devastating Eaton Fire in January 2025, two assisted-living facilities in Los Angeles County experienced major evacuation failures that placed elderly residents at severe risk. According to a detailed investigation by the California Department of Social Services (CDSS), both MonteCedro and The Terraces at Park Marino left residents behind as flames approached, highlighting critical breakdowns in emergency preparedness and staff training.

You can read the full report in the Los Angeles Times here: State investigators find serious lapses during the Eaton Fire evacuation.

For members of the Long Term Care Resources Alliance (LTCRA), this incident is not just a headline — it is a powerful reminder of why emergency readiness, staff competence, and resident-location protocols must be embedded into your operational culture.

What Went Wrong — And What It Means for Long-Term Care

At MonteCedro, leadership left the building during the critical overnight hours, and most administrative staff — the only ones properly trained in emergency procedures — went home. State investigators found that even after the facility evacuated roughly 200 residents, two elderly women, including a 100-year-old, were discovered hours later still inside the building. Deputies found one resident wandering the halls as flames were visible outside her window.

At The Terraces at Park Marino, staff initially reported that all residents had been evacuated. Only later — after a concerned family member called 911 — did officials learn that a wheelchair-bound woman remained inside her room. Firefighters rescued her as the structure began to burn. These failures underscore a simple but urgent truth:
Emergency plans are only as strong as the staff who know them, practice them, and follow them.

As USC’s Dr. Laura Mosqueda put it in the investigation:

“To evacuate and not have a complete list and know you’ve gotten everybody out … is not OK.”
(Source: L.A. Times — serious lapses found during Eaton Fire)

Top 5 Action Steps LTCRA Members Must Take Immediately

1. Provide Comprehensive, All-Staff Emergency Training

Do not limit emergency-plan education to administrative roles.
Investigators discovered that the MonteCedro team relied on the very people who left the building when the fire escalated.

Staff at all levels — including caregivers, security, agency personnel, and overnight/holiday shifts — must be fully trained.

2. Implement a True 24/7 Staff Recall System

CDSS investigators noted that MonteCedro referenced a recall list in their emergency binder, but no list actually existed.
Every LTCRA-affiliated facility should maintain:

• a current roster
• all contact numbers
• designated roles
• secondary backups

A recall system must be actionable within minutes — not theoretical.

3. Enforce Resident-Location Verification at Every Stage

Failure to track residents was a major deficiency cited under state law.
Your protocol should include:

• Room-by-room sweeps
• Pre-evacuation roll-call
• Arrival roll-call
• Secondary sweeps of all floors
• Transportation manifesting

This is essential in memory care, assisted living, and skilled nursing environments.

4. Ensure Clear, On-Site Leadership Accountability

One of the most shocking findings was that MonteCedro’s executive director left the property before briefing staff on evacuation plans.

Your emergency plan must define:

• Who is the incident commander
• Who has authority if they’re off site
• Who cannot leave under any circumstances
• When leadership relief must occur

Leadership presence can be the difference between a coordinated evacuation and a tragedy.

5. Strengthen Coordination with Local Fire, EMS & Evacuation Shelters

These two evacuations happened during massive pressure on local fire and sheriff resources.
Facilities must proactively build relationships with:

• City/county fire departments
• Emergency Management Offices
• Local hospitals
• Nearby senior-care centers
• Designated evacuation sites

This aligns with LTCRA’s ongoing mission to build safer, more resilient long-term-care systems. Learn more at LTCRA’s emergency preparedness resources.

Why This Matters for Liability, Compliance & Reputation

The Eaton Fire is a textbook example of how quickly reputational and regulatory damage can occur when emergency systems fail.

CDSS cited multiple violations of the Health & Safety Code for:

• Improper training
• Missing residents
• Failure to verify location
• Leadership abandonment of duty
• Immediate risks to persons in care

This should be an urgent wake-up call for every senior-care operator — especially as wildfires, hurricanes, extreme heat, and flooding events increase nationwide.

Next Steps for LTCRA-Affiliated Providers

Below are actionable steps your organization should complete this quarter:

✔ Conduct a full emergency-plan gap analysis

Check for missing recall lists, outdated staff roles, missing transportation plans, or unclear responsibilities.

✔ Run a wildfire-speed tabletop drill

Simulate:

• minimal staffing
• missing residents
• nighttime conditions
• delayed transport arrival
• smoke infiltration
• family-member 911 calls

✔ Review evacuation transportation partnerships

• Do you have buses? Vans? ADA-compliant vehicles?
• Are agreements active or expired?

✔ Audit training records across shifts

Night shift and weekend staff must be included.

✔ Strengthen your communication plan

Include:

• Family notifications
• Media statements
• Resident status tracking
• Documentation templates

Final Reflection

The Eaton Fire showed us exactly what happens when emergency readiness is treated as a binder instead of a lived practice. For LTCRA members, the message is clear:

• Prepare proactively.
  
• Train comprehensively.
  
• Lead visibly.
  
• Verify every resident, every time.

By learning from MonteCedro and The Terraces, LTCRA providers can build safer communities and protect the lives entrusted to their care.