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hey’ve been here for hours: buses full of seniors still idling in the parking lot. Hundreds of white-haired and bald fire refugees, some of them still in their pajamas, lean on walkers or sit on folding chairs scattered on the sidewalk outside the door of the evacuation center, waiting. They ended up here, at the Veterans Memorial Building in Santa Rosa, in the very early morning hours of Sept. 28, 2020, after the fast-moving Glass Fire forced them out of bed at the retirement communities where they live.

But after hours of waiting for a cot, there's no sign they will be allowed in anytime soon, or at all.

“They were absolutely not ready for us,” said Pierre LaBerge, 86, who helped his fellow residents evacuate their retirement community that night, and who has fled his home three times in the last four years. “The previous time, it was very efficient. But this has been not too perfect.”

This time, there’s a pandemic on top of a wildfire, and the evacuation centers can only admit a fraction of evacuees in order to maintain safe social distance between cots. This time, the fire is moving even faster, and the evacuation center may itself have to evacuate.

A man in an orange vest jumps up on one of the folding chairs to announce that, because of rapidly shifting fire behavior, they are no longer accepting people here at the vets building. Everyone out here will have to move on to another evacuation center, 18 miles away in Petaluma.

“What I have to caution you against,” he shouts to the crowd, “is getting your hopes up that you are going to walk into a bed over there. It is likely going to be like this again.”

More crowds and more waiting, as the county races to set up the next evacuation site. Sleep is still hours away for these seniors, but no one groans or complains. They seem stoic, Zen, or perhaps resigned. They line up to re-board the buses.

This is not how this was supposed to go. Hundreds of seniors, most of them mobile and independent, but also many who are infirm, in wheelchairs or with dementia, waiting outside in the literal cold, being shuttled from one evacuation site to another.

“That’s not the plan,” said Crista Barnett Nelson, who leads Sonoma County’s long-term care ombudsman program. “These were very frail individuals and they should not have been there.”

Facilities, Evacuation Sites Not Ready for Glass Fire

Sonoma County officials say at least half a dozen long-term care facilities brought as many as 100 of their residents to public evacuation shelters starting late on the night of Sept. 27.

As fires across the state become more frequent and intense, some long-term care facilities are, in turn, leaning harder on public resources in evacuations. What happened in Sonoma County during the Glass Fire has sparked a dispute among care homes, county officials and regulators – and it reveals a shifting understanding in California about what’s owed to vulnerable residents in the path of fire, and by whom.

“The fact that they were not ready for the fire, it's inexcusable,” said Sonoma County Supervisor Shirlee Zane, who visited evacuation sites after the Glass Fire, where she saw several long-term care residents in the crowd of elderly evacuees.

Earlier this year, a KQED investigation found that 35% of the state’s long-term care homes are in areas at risk for fire. All must have some form of an emergency plan: multiple sites to which they can relocate, feasible transportation and safeguards for the well-being of residents along the way. But regulators for assisted living have almost never found problems with these plans, and nursing home surveyors rarely follow up in person even when deficiencies are found.

More and more care homes are seeking shelter from fires: this year, 27 fires have caused more than 100 facilities to evacuate and relocate nearly 2,400 adults, according to the California Department of Social Services.

COVID-19 has complicated emergency planning and underlined its importance. Advocates for elderly and disabled care home residents say the state’s weak oversight has left facilities unprepared for one emergency, let alone two happening at the same time.

“They have a hand in the responsibility of holding these facilities accountable, and that's what I'm asking of them,” said Paul Dunaway, director of adult and aging services for Sonoma County’s Human Services Department. “I think that the community needs to ask the same.”

The Eye of the Firestorm and the Birth of a Law

In recent years, wildfire has been threatening care homes all over the state, but Sonoma County has become the epicenter for repeated evacuations of elderly residents. In 2017, the fast-moving Tubbs Fire – which killed 22 people and destroyed about 5,600 homes – revealed gaping holes in emergency plans at two assisted living facilities and spurred new rules to strengthen preparations for future fires.

As the flames approached the Villa Capri and Varenna facilities in Santa Rosa, overnight staff were paralyzed. They had never been trained in evacuations. The printed emergency plan was in a locked office, inaccessible. Keys to vans that could have carried residents to safety were nowhere to be found. Staff used their personal cars to shuttle handfuls of residents out of the area, but left about 100 seniors stranded at the facilities.

Family members and police ultimately came to rescue the remaining seniors, many with dementia or in wheelchairs, shortly before Villa Capri burned to the ground.

“It felt terrible – like you’ve really been abandoned,” said Alice Eurotas, 87. “Leaving all of these elderly people, many of whom cannot walk, to fight the flames? That doesn't work.”

After that, advocates and officials stepped in to demand better plans.

Under a new state law that took effect in 2019, assisted living facilities are now required to set up two safe relocation sites to take residents in an emergency, a reliable means of transportation to get there and a way to communicate with far-away family members that their elderly loved ones are OK.

As yet another fire zoomed toward the city in late September, Santa Rosa care homes had to put their new, revised emergency plans to the test.

Residents 'Suffered' at Congregate Shelters

As the county evacuation shelters began filling up with frail residents from local elder care homes, Crista Barnett Nelson was awakened by a phone call around 3 a.m. Ambulances carrying bed-bound elderly people from a small assisted living facility were pulling up to the Petaluma Veterans Building, and county health officials were concerned the shelter was not the appropriate place for them to be housed, even temporarily, because of their intensive care needs and the risk of coronavirus exposure. Barnett Nelson went down there to redirect.

“They called and said, ‘They’re not supposed to be here,’ ” Barnett Nelson remembers. "That's not the plan."

As Sonoma County’s long-term care ombudsman, Barnett Nelson investigates elder abuse and advocates for residents at assisted living and skilled nursing facilities, including through an emergency evacuation.

“My role that evening is to ensure their safety and ensure that all the systems are working that had been planned,” she said. “And then to aid in getting them moved to a more safe environment.”

Six different facilities arrived at public shelters that night, she said. She helped staff from Hill House, whose six residents arrived in a series of ambulances, find another place they could go. She turned another facility, Betsy’s II care home, away at the door, because they had a sister facility they could go to. Oakmont Gardens stayed one night then arranged placements for its roughly 40 assisted living residents. But Spring Lake Village needed more time to make new arrangements after its original relocation sites fell through.

Several seniors left at the public shelters had dementia.

“It was very confusing for them and very disorienting,” said Barnett Nelson, who visited them at the shelter every day.

She described one woman with dementia who flagged her down after the first night.

“She said, ‘Excuse me, ma’am? I’ve chosen to stay. I would like a cot, please,’ ” Barnett Nelson remembers. Even though the woman had already stayed the night before and already had a cot.

Barnett Nelson played along and replied, “Absolutely, let me see what I can find for you.”

But as she started to step away, the woman pulled her aside again and said, “Excuse me, ma’am. I think I want a cot.”

The woman was making the decision to stay over and over again, Barnett Nelson said. Weighing pros and cons, worrying about what-ifs. It was just on repeat in her mind, the anxiety looping around and around.

“You could tell for her it was a big decision,” Barnett Nelson said. “But it’s over and over and over again.”

This is why change is so distressing for people with dementia, and why it’s so important that they not be moved around multiple times or left in limbo. This is one of the things the new law was supposed to protect against, in Barnett Nelson’s view, by requiring facilities to have a plan in place for where dementia residents can be taken right away in an emergency.

While other facilities were able to move their residents out of the shelters after one day, Spring Lake Village, a large senior living community that includes assisted living, took four days to finish finding placements for all of its residents.

“That’s too long,” Barnett Nelson said. “Yes, they had to get them out, but you don’t put them in an evacuation shelter for three days while you figure it out. There’s no excuse for that.”

She, along with the county’s Paul Dunaway, were so disturbed by the evacuations, they filed a rare complaint with state regulators. They argued emergency plans should be so robust that facilities, especially the large ones, should not need to rely on public shelters the way they did.

“These are private companies and they’re paid to follow these things all the way through,” Barnett Nelson said. “How do you not have Plan A, Plan B, Plan C, Plan D when you have 400 peoples' lives in your hands?”

Plans Scuttled by Power Shutoffs, Pandemic

At Spring Lake Village, a property in Santa Rosa owned by the nonprofit Covia, Senior Vice President for Organizational Advancement Mary McMullin said they had a Plan A. And a Plan B, and a few letters beyond that. But fire – and COVID-19 – confounded them all.

Early on the morning of Sept. 27, a Nixle alert warned of smoke and ash, but said fire wasn’t a threat to Sonoma County. Then winds shifted. By evening, scanner traffic reported “extreme fire behavior,” with long flames creating new hot spots a mile or more ahead of the fire itself, torch-like conditions that had taken lives in 2017.

For Spring Lake Village’s neighborhood, an evacuation warning sounded around 10 p.m., with orders to get out issued less than an hour later.

As a continuing care retirement community, Spring Lake Village offers independent living to nearly 400 seniors, as well as assisted living and a skilled nursing facility. So its wildfire plan had to meet state and federal standards, overseen by multiple agencies.

For those living on their own, Spring Lake Village created a buddy system, where residents checked on each other. McMullin and some residents say that worked better than in previous wildfires.

“Nobody expects to be evacuated,” said Pierre LaBerge, a volunteer fire warden who helped oversee the Glass Fire departures. “You know, they don't really mean it this time, do they?”

Some people left to stay with friends or family; others had signed up to take a pre-arranged bus to a hotel in Tahoe. But that night, McMullin said the Tahoe hotel was subject to a power shutoff meant to prevent wildfire starts and couldn’t check in nearly 100 seniors.

For assisted living, Spring Lake Village had “handshake agreements” with facilities outside of the area to accept short-term about two dozen residents who need some help with daily activities. Because of the pandemic, those agreements fell through.

“The relationships we had, when push came to shove, they were unwilling to accept people due to the COVID restrictions and not wanting to put their residents at risk,” McMullin said.

Some of Spring Lake Village’s 51 skilled nursing patients headed directly for St. Paul’s Towers in Oakland, a sister facility also owned by Covia. McMullin said the plan was to take the rest to other Covia properties, including Webster House in Palo Alto. But she said families of some residents didn’t want them to go that far.

That’s why Spring Lake Village sent so many people to Veterans Memorial on Sunday night. McMullin defends the decision, pointing out that more than two dozen staffers boarded buses and drove cars to the shelters to help.

She also said the county directed Spring Lake Village to go to the congregate shelter.

“Why else would we have gone there?” she said. “It wasn't like we just stuck a finger up in the wind and said, where are we going, you know?”

McMullin said the county got “caught a little flat-footed” that Sunday night. But Sonoma County spokeswoman Carly Cabrera disagrees.

“The county was not aware of [Spring Lake Village’s] evacuation plans before the arrival of patients from the facility to the Santa Rosa Veterans Building,” she said. Once they arrived, she said the county helped “craft a plan to move 12 skilled nursing patients to the Cloverdale Health Center by the next day.”

Regulators Side With Facilities

Sonoma County complained to state regulators and said it has opened a local investigation into what happened.

But state regulators dismiss the county’s concerns that care homes didn’t have good plans in place, and that they were relying too heavily on public resources. In a written statement, the California Department of Social Services, which regulates assisted living facilities, called the actions of facilities “appropriate,” and said their plans meet state standards.

“If the plan cannot be followed due to extenuating circumstances, they may use public resources, such as a shelter, to ensure the health and safety of residents in care,” the department wrote.

Both CDSS and the California Department of Public Health, which regulates nursing homes, said they help facilities by strategizing how to evacuate, finding placements for their charges, and marshalling any public resources they can to help. For example, CDSS said it worked with officials at the Petaluma fairgrounds to secure a private room for Spring Lake Village evacuees for four nights.

Neither regulator finds fault with the evacuations. CDPH issued no deficiencies related to what the department’s surveyor saw at the evacuation sites during the Glass Fire, and CDSS said it’s not investigating any assisted living responses.

County officials and advocates for the elderly say if the state won’t hold the facilities accountable, the community will have to. Residents who pay high monthly rents and service fees will have to demand better emergency plans for their money, said Barnett Nelson, the Sonoma County long-term care ombudsman.

“At the end of the day, we have to stop relying on government to make people do the right thing,” she said. “They need to do it because it’s the right thing to do and they’re getting paid a lot of money to do it.”

Evacuations Bring Trauma, Confusion and Uncertainty

Communities like Spring Lake Village aim to reduce uncertainty about where to live for older residents as their health needs are changing. Even under the best-executed plans, wildfire and evacuations directly undermine that.

Evacuations cause emotional and physical trauma for older people. Studies have shown that people with dementia are at higher risk of death in the months following a natural disaster, like a wildfire.

“There's no question that it takes a toll on you,” said Pierre LaBerge. “I mean, it’s spooky. The sky is all smoky and fiery, and people are walking around, not knowing what to do.”

Evacuation for older people is hard on family members, too. Barb Nesbett’s parents, Betty and Barney Johnson met on a blind date at Tommy’s Joynt in San Francisco; they spent more than half a century in the same house before deciding to move to Spring Lake Village.

“They didn’t want us, the kids, to worry about them,” Nesbett said.

But when the fires broke out last month, Nesbett and her dad, who was in independent living, didn’t know where her mom, a skilled nursing patient, was taken.

Nesbett emailed the facility multiple times and posted on Facebook, but it was days before a Spring Lake Village staffer called her.

“She felt just awful that no one had gotten back to me,” Nesbett said through tears. “But she did see my mom and assured me my mom was fine.”

Now back at Spring Lake Village, her parents are quarantined against the risk of the pandemic. Her father can only wave to her mother through a window. That isolation and these evacuations - this is not the way old age is supposed to go, Nesbett said.

“That's not how my parents envisioned these years,” she said. “It’s just been awful and it’s heartbreaking.”

Is Santa Rosa the Right Place to Retire?

For all of the confusion and finger pointing about who should have done what better with these evacuations, the real villain is wildfire. The villain is climate change, and the uncertainty and unpredictability of how it will impact the winds and heat that conspire to create these infernos.

But we do know that the winds will keep blowing and the fires will continue to erupt. And we know they’re getting worse.

Climate change has made major fires in California more common and more destructive - including those in Santa Rosa, raising questions about whether the city is really a safe place for seniors to retire.

“In light of two fires in three years, what is the market viability of that community in the long run? You know? And will residents choose to be there?” said Covia’s Mary McMullin.

But she adds that it’s a statewide concern, not just a Spring Lake Village one.

“People are safer with us because we're equipped. There's no doubt about that. If someone said, should I still move in? I would say absolutely,” she said. “I know it's traumatizing for residents.”

But Barnett Nelson points out that after the Tubbs Fire roared through, many people in Sonoma County treated it like an anomaly.

“They started rebuilding immediately in the exact same spot,” she said, referring to the owners of Villa Capri, who rebuilt on the same land where residents were abandoned in 2017 and where fire has returned, again and again.

“People who were here in the '60s when there weren't homes said, ‘Don't build homes there. That's a fire zone!’ ” said Crista Barnett Nelson. “And then they grew old and probably passed and they built homes there.”

Pierre LaBerge has returned to his Spring Lake Village home – though he, too, is growing weary of the heat, the fires, the evacuations.

LaBerge and his wife retired to Santa Rosa more than 20 years ago, settling in the Fountaingrove neighborhood. His home there burned to the ground not long after he sold it to move to Spring Lake Village.

LaBerge said he and his neighbors are living through the results of global warming: new conditions, to which everyone needs to adapt.

“We’ve got to be smarter ... We’re on a learning curve,” he said. “Nothing’s the same as it was. And you’ve got to accept that.”

LaBerge muses about where else he might have retired to, what other conditions might have threatened their homes: tornadoes, snowstorms, floods. But he and his wife love California. And he said they’re too old to move.

“Would we have picked here again?” he asked himself. “I dunno. I doubt it.”

Gabe Meline, Joe Fitzgerald Rodriguez and Lisa Pickoff-White contributed reporting to this story.