97-year-old woman left alone in senior facility with Eaton fire outside her window. What went wrong?

When her son Jim Benesh called to check on her, he was shocked to learn she was still in her room. He jumped in his car and sped to the nursing home, where he found her in an empty building.

“There she was sitting on her couch — with the fire outside her window,” he said. “It’s unbelievable.”

As the Los Angeles County Board of Supervisors and local members of Congress direct separate investigations into electronic alert failures and delayed evacuation orders in Altadena during the Jan. 7 firestorm, the California Department of Social Services has confirmed that it is investigating at least two instances in which elderly women appear to have been forgotten at senior care facilities during the Eaton fire, including Dorothy Benesh.

At the same time, relatives and elder care advocates say the abandonment of California seniors at licensed care facilities during wildfires is a growing problem. They are demanding that the state impose more stringent safety procedures for assisted care operators so that nobody is left behind during an emergency evacuation.

“Those procedures need to be updated, they need to be able to check and make sure that everybody’s out of those buildings,” Jim Benesh said. “Why wouldn’t they go back and check every room and make sure everybody got out?”

Adam Khalifa, president and chief executive of the Terraces at Park Marino, did not dispute what happened to the Benesh family, but told The Times that his staff followed its disaster plan, which was approved by the state. He did not detail what procedures are outlined in that plan.

Khalifa told The Times that staff members and firefighters moved residents to safety about 8:30 p.m.

“Our staff went back to do a final sweep and were denied access by firefighters,” Khalifa said. Staff members tried at least twice to get back inside — around 8:45 to 9:10 p.m. — but were told they could not do so. About 9:15 p.m. firefighters told them that “they had successfully cleared the entire building,” he said.

Benesh said he understands that conditions that night were frighteningly chaotic — harrowing video shows seniors in nightgowns and wheelchairs fleeing the Terraces and other nearby facilities as dangerous winds and embers swirled about — but that there’s no excuse for what happened to his mother.

The facility, which would ultimately be destroyed in the fire, fell within an area that was ordered to evacuate at 7:26 p.m. — roughly an hour after the blaze started.

Jim Benesh had been checking in with his mother by phone and called her a third time about 8:45 p.m., when he could see smoke billowing from the foothills.

“I said, ‘Mom, the fire’s everywhere,’” he told The Times. “She said, ‘Well, the alarm’s not going off anymore.’”

He raced to get to her, passing emergency vehicles as he neared the facility. At one point, he realized he wouldn’t make it to his mom without ignoring some of roadblocks.

“Honestly, I don’t know how I got to her,” Jim Benesh said. “I got to the facility, and all of the landscaping around the building was on fire, and the wind was blowing embers everywhere.”

He said he rushed through the unpowered automatic doors into an empty and waterlogged lobby. He took a stairwell to his mom’s third-floor room, yelling out for anyone. He found his mom’s apartment door closed, the only one in the hallway. He burst inside and quickly led his mom, who uses a walker, to safety.

It would be almost three hours before the assisted living facility’s staff would reach out to see whether his mother was with him.

“I said, ‘Yeah, she’s with me, thank goodness, because if she hadn’t been she’d been dead,’” Jim Benesh said, choking up as he recalled the episode.

It’s not clear exactly when Jim Benesh found his mom and got her out. According to the son’s recollection and a Times review of his phone logs, he got his mother out about 9:15 p.m.

Khalifa didn’t address why it took several hours for staff to confirm that Dorothy Benesh was with her family, but he said that night they called all residents’ families “and ensured that all residents were safe and accounted for.”

The Department of Social Services, which licenses and oversees assisted living facilities, confirmed that it has opened an investigation into what happened at the Terraces at Park Marino during the Eaton fire evacuation, department spokesperson Jason Montiel said.

The agency has also launched an investigation into what happened at MonteCedro, the assisted living facility in west Altadena where two elderly women were left behind and later discovered by sheriff’s deputies.

Montiel declined to comment further on either investigation.

California assisted living providers are required by the state to have a “disaster and mass casualty plan” that includes training and drills, but it’s unclear exactly how detailed and rigorous those plans have to be. The Department of Social Services did not immediately respond to questions about those requirements.

Although both facilities were recently evaluated by state investigators and appeared to be in good standing, the department did list the Terraces at Park Marino as having 17 “Type A” citations, which are defined as an “immediate health, safety or personal rights impact.” The department’s website clarified that some of those citations may be under appeal. It was unclear whether any of the citations were related to emergency preparedness.

Elder care advocates say what happened during the Eaton fire underscores the fact that seniors are the most vulnerable population in wildfires.

“This is a huge issue,” said Anne Belden, co-author of the book “Inflamed: Abandonment, Heroism, and Outrage in Wine Country’s Deadliest Firestorm,” which investigated the botched evacuation of two Santa Rosa, Calif., senior facilities during the 2017 Tubbs fire.

“It shouldn’t be the job of children of these residents to rescue them; that’s the job of the assistant living community.”

Belden said the problem will only worsen without more stringent safety requirements.

“You have the convergence of these climate-change-induced disasters … getting bigger and badder than ever before, along with this booming assisted living industry,” Belden said.

In the investigation into the pair of Santa Rosa senior homes, where dozens of residents narrowly escaped after staff members abandoned the facilities, she and her co-authors found that despite being billed and marketed as a high-end senior community, the facilities’ emergency plans were almost nonexistent. They also found that the staff members working that night were inadequately trained on any such procedures.

“This is a multibillion-dollar industry,” Belden said. “Nice doesn’t necessarily mean safe. You can have a culture of luxury, but you need a culture of safety. ... Requirements for practical training of staff for the emergencies we’re seeing, especially in California, would go a long way.”

After Santa Rosa, state lawmakers passed a bill to establish stronger emergency planning rules for assisted living facilities, requiring more frequent drills and training, ensuring keys to certain vehicles are available to staff and designating potential evacuation destinations. However, a KQED investigation found in 2020 that such facilities were rarely held accountable if they failed to comply.

Belden also noted that assisted living facilities are not bound by the same federal emergency preparedness requirements that nursing homes — which provide higher level of care — must adhere to. That leaves a messy patchwork of rules governing increasingly popular assisted living communities, Belden said.

Beth Eurotas-Steffy, whose mother was among those abandoned at the Villa Capri assisted living facility in Santa Rosa during the Tubbs fire, echoed concerns that California’s updated requirements are still lacking. Ever since her late mother, Alice Eurotas, was left behind and rescued by relatives of another senior, Eurotas-Steffy said, she has been urging lawmakers to consider measures focused on increased staffing levels, mandated training, emergency drills and backup power requirements similar to those adopted in Florida in 2018.

After 12 seniors died when they were stuck for days without air conditioning in the wake of Hurricane Irma, Florida lawmakers required that senior homes have 72 hours of backup power. Eurotas-Steffy said she would like to see a similar measure enacted in California so that elevators can keep operating, lights will stay on and lifesaving devices will continue operating during emergencies.

“Florida did it,” Eurotas-Steffy said. “With all of our fires and all of our climate-related disasters [in California] and we’re going to keep saying no? … Aren’t our seniors worth it?”