SANTA ROSA, Calif. (KGO) -- The California Department of Social Services has completed the investigations into the October 2017 wildfire evacuations of three state licensed assisted living facilities in Santa Rosa -- Varenna, Villa Capri and Fountaingrove Lodge.
Based on evidence gathered during the investigations and the statements of witnesses, the department has determined that Oakmont Senior Living failed to protect the health and safety of residents at Varenna and Villa Capri. The department served Oakmont Senior Living with legal notice to revoke the licenses of Varenna and Villa Capri.
Villa Capri burned down during the October 2017 Tubbs fire, but Varenna did not and still has residents living there. Oakmont Senior Living now has 15 days to appeal and request a hearing before an administrative law judge.
In a scathing 18 page legal notice, DSS details a lack of staff training.
There were four staff members on duty overnight at Villa Capri for 62 elderly and disabled residents.
DSS says Villa Capri Executive Director Deborah Smith failed to ensure those four staff members were familiar with Villa Capri's planned emergency procedures. The four had never participated in a fire drill.
DSS says they left more than 20 elderly residents at Villa Capri the night of the fire.
Family member Kathy Allen helped rescue them.
"All I could think about was getting all those people to safety," Allen told ABC7 News in 2017.
DSS says had it not been for family members and emergency responders, "more than 20 residents would have perished."
DSS says there were two care staff members and two maintenance staff members on duty overnight for 228 residents at the Varenna building.
"I wasn't really paying attention to what was burning, how it was burning, I was just focused on how to get the hell out of there," maintenance worker Andre Blakely told ABC7 News after the fire.
DSS says Blakely and two other employees were evacuating residents from their rooms when Varenna Executive Director Nathan Condie told them to bring residents back to their rooms because he didn't want to "cause issues" or "make trouble."
DSS says Condie then left more than 70 residents with three staff members not trained in evacuation procedures.
Family member RJ Kisling helped evacuate those 70 plus residents.
"I knew that I needed to be the answer," Kisling told ABC7 News in 2017.
DSS says three Varenna residents were never evacuated and learned the following morning an evacuation took place while they were asleep.
DSS says Oakmont Senior Living made false and misleading statements about those three residents when it said they had been evacuated from the building and is now calling for executive directors Deborah Smith and Nathan Condie to be prohibited from ever being a licensee or being employed at a licensed facility again.
ABC7 News reached out to both for comment but did not hear back. DSS also looked at a third building known as Fountaingrove Lodge but did not find reason to take action there.
Get the latest updates on the North Bay Fires here.