ABC7 News obtained a copy of that report.
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In it, the Department of Social Services details how it went about its investigation. DSS says it interviewed 10 staff, 10 residents, first responders, city officials, family members and other witnesses. The department also says it reviewed the Santa Rosa Police Department reports and body camera footage as well as resident records, the facility's "Plan of Operation" and the facility's "Disaster Planning" policies and procedure dated February 16, 2017.
RELATED: DSS serves North Bay Assisted Living Facilities with legal notice to revoke licenses after wildfire investigation
According to the complaint investigation report, a staff member who was interviewed but not at the facility the night of the fire stated that since they had started working at Villa Capri, beginning February of 2016, they had not conducted a disaster drill where all residents and staff evacuated the building.
DSS writes in its report that, "The manual, on page 82, explains that the Primary Emergency Assembly Point (EAP) is to 'coordinate a head count of all residents, staff, and visitors using the Resident Roster, Visitor Sign-In/Out Sheet, and Employee Sign-In/Out Sheet,' and 'If it is safe to do so, the appropriate Safety Supervisors conduct a sweep of their areas of the building to locate any individuals not accounted for during the head count.' DSS writes, "Based on the staff interviews, these steps were not taken by S5, S7, S8 and S9."
NORTH BAY FIRES: An investigation into the evacuation of Oakmont Senior Living in Santa Rosa
In its report DSS says staff did not have adequate training in emergency disaster procedures. Specifically, "When S7 was hired they were told what to do if the fire was inside the building, but did not know anything about what to do if they needed to evacuate due to an emergency outside the building.
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Last Thursday, DSS served Oakmont Senior Living with a legal notice to revoke the licenses of Varenna and Villa Capri and to exclude the administrators of both facilities for life.
RELATED: Family of loved one who passed after Oakmont Senior Living fire speaks out
DSS says had it not been for family members and emergency responders, "More than 20 residents would have perished."
Oakmont Senior Living has 15 days to appeal and request a hearing before an administrative law judge.
Get the latest updates on the North Bay Fires here.