The Terraces at Park Marino once stood less than 2 miles from where the Eaton Fire started in the foothills above the Pasadena-Altadena border on the evening of Jan. 7.

By the time the assisted living community burned to the ground, all of its nearly 100 residents had gotten out.

But the last resident to exit — a woman who uses a wheelchair — remained inside her third-floor room for hours before Pasadena firefighters reached her and brought her to safety, according to a state investigation report released over the summer.

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The California Department of Social Services cited The Terraces in August, saying authorities there had left the woman behind in room 326 — a violation of her personal rights as a care facility resident.

The facility denies that and has since appealed. They say first responders were in charge of evacuation efforts that night, not staff. And they say staff alerted firefighters about the woman in room 326 after they arrived on the scene.

“[She] was never abandoned,” said Adam Khalifa, chief executive of Diversified Health Services, in a statement. The organization owns and operates the facility.

“She was rescued by firefighters after our staff alerted them that she was unable to evacuate from the third floor because she requires a wheelchair and the elevators were out,” the statement continued.

The dispute between the facility and state officials has raised questions about who’s responsible for keeping track of residents at residential care facilities during an emergency evacuation, as well as how complaints are investigated and reported to the public.

The Terraces is one of two residential care facilities that state authorities cited for failing to properly account for residents during evacuations. The other — MonteCedro in Altadena — is still standing. State licensing authorities said they cannot comment on pending appeals.

The complaint that launched the investigation

When the state's investigation into The Terraces' evacuation began in February, licensing authorities were looking into a separate allegation. That initial complaint was connected to a resident named Dorothy Benesh who lived in room 315 of The Terraces, not the woman in room 326 who was rescued by Pasadena Fire personnel.

The details in the state’s initial investigation into the complaint into what happened in room 315 match allegations Jim Benesh told LAist and the Los Angeles Times. Benesh said that he rescued his mother Dorothy from her room in The Terraces after he called her on the phone repeatedly and determined she needed help. He said staff left her in her room for at least two hours after they began moving others down to the lobby.

Benesh told LAist he did not contact the California Department of Social Services to file a complaint but did tell investigators what happened when they called him with questions.

“I responded and told them I wished the protocol for evacuation was better, so that they actually check the building for everyone left behind and not just assume everyone got out,” Benesh said. “Because my mom didn't get out — until I got there.”

State investigators were not able to substantiate the complaint that matches Benesh’s allegation.

But over the course of their investigation, they determined a different person — the woman in room 326 — had been left behind during the evacuations.

The California Department of Social Services said that’s what led to the citation, according to the report.

Residents are not identified by name in state investigative reports. LAist was not able to identify or contact the woman in room 326 who the state says was left behind or her family.

LAist reached out to over a dozen former residents and family members for this story. Multiple residents told LAist the buildings were safely evacuated on Jan. 7.

Serena Bernolak’s mother was at The Terraces in January and was among the evacuees. Bernolak said she “firmly” believes staff at the facility did their best as the fast-moving Eaton Fire advanced. But, she said, there’s room for improvement.

“I think there should be some type of reform so that when a situation like this comes up, these care facilities are evacuated immediately,” Bernolak said.

Residents of The Terraces and other facilities are evacuated as the Eaton Fire approaches on Jan. 7, 2025, in Altadena.

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Ethan Swope

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Associated Press

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How the evacuations unfolded 

On Jan. 7, staff at The Terraces started gathering residents in the lobby around 7 p.m, according to the state report. That was about a half an hour after they first spotted flames on a nearby hillside.

At 7:26 p.m., L.A. County officials sent evacuation orders to the area, according to the county Office of Emergency Management. But staff at The Terraces said they did not receive an evacuation notification because power was out, according to the state citation.

Bernolak was texting with facility staff soon after the fire started to find out whether her mother, Anna Ruggiero, was OK. Bernolak was unprepared to care for her mother at home because she was completely immobile, she told LAist. At 8:18 p.m., Bernolak texted an employee at The Terraces.

“Hi,” she wrote, according to screenshots of text messages reviewed by LAist. “Are there plans to evacuate?”

The Terraces employee replied at 8:31 p.m., according to the screenshots: “You should come get your mom asap. Not worried about fire, but smoke is coming in”

Bernolak told LAist she dashed out the door of her home in East Pasadena and arrived at The Terraces less than 10 minutes later.

According to fire authorities, the Pasadena Fire Department arrived at The Terraces by 8:30 p.m. By then, two sides of the building were burning, Capt. Trey Sorensen told LAist, in a statement.

Some people were being transported away in private ambulances and personal cars. Most were sheltering in place and awaiting further instruction, Sorensen said on a podcast in April.

Once fire conditions worsened, Sorenson "directed residents and staff to be relocated to avoid loss of life," according to a written statement provided to LAist by a city of Pasadena spokesperson.

Between 8:45 p.m. and 9:15 p.m., staff members tried to get back inside the burning building to continue the evacuations, but firefighters wouldn’t let them enter, state investigators wrote in their report.

Around this time, someone alerted the Pasadena Fire Department about the woman still inside room 326, investigators wrote. The state report said she was rescued by Pasadena Fire after her “responsible party” called Pasadena police.

Exactly who first alerted authorities that the woman needed rescue is under dispute.

A spokesperson for the city of Pasadena told LAist in November that the woman in room 326 was evacuated by the Pasadena Fire Department after the Pasadena Police Department “received a call from their family member stating they needed assistance.”

Representatives for The Terraces have said in state appeals and statements to LAist that it was facility staff who notified authorities that the woman was still in her room.

Administrators and staff from The Terraces did not agree to be interviewed, but the CEO that operates the facility and one caregiver provided written statements to LAist, through a public relations specialist.

Zion Brown worked in The Terraces’ memory care unit as the lead medication technician. He and his co-workers made multiple trips carrying residents down from the upper floors, he told LAist in a written statement.

“The last time we went back up, we were overtaken by firefighters who told us we had to get out [of] the building, which was on fire," Brown said. “I told them there was still someone in room 326 and they said they would evacuate that resident.”

The Pasadena Police Department told LAist that it had no record of any 911 calls associated with The Terraces evacuation. The tip was provided in the field, according to a statement from Pasadena Police Department Administrator Alicia Patterson.

“The information was relayed by an evacuee to the command post,” Patterson wrote. “The information was then relayed to fire personnel.”

A wheelchair left in the 7-Eleven parking lot on Jan. 8, 2025, after several care facilities staged evacuations there the night prior, including The Terraces at Park Marino.

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Sharon McNary

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LAist

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In an August appeal of the state’s findings, operators at The Terraces said their staff no longer had control over the evacuation once first responders showed up.

They cited a section of state law that says firefighters can restrict access to disaster areas, and that those who refuse to comply can be charged with a misdemeanor.

News footage from the scene shows staff from The Terraces working with fire personnel and sheriff’s deputies to move dozens of residents to a nearby 7-Eleven parking lot and then onto city buses.

Sorensen recounted the chaotic evacuation of the woman in room 326 in the podcast interview, saying firefighters came “down the stairwell with the wheelchair. … This lady, her head is wrapped in a blanket and towel so that she doesn’t get smoke inhalation. They’re like, ‘Where are we going?’ I’m like ‘7-Eleven.’”

Bernolak, who received a text message from The Terraces to pick up her mother as the fire neared, said she is thankful for what The Terraces staff did to help move her mother and many others to safety.

She said the facility’s medical director carried her mother down three flights of stairs and helped her onto a bus.

“ He put himself in harm's way to get my mom out of the building,” Bernolak said.

The timeline at The Terraces

Emergency planning

LAist filed a public records request seeking incident reports, service logs and 911 call recordings documenting the Pasadena police and fire departments’ response to The Terraces that night, along with other nearby facilities that were evacuated. Pasadena authorities said no such records exist.

Sorensen, the Pasadena fire captain who led the city response at the facility, praised The Terraces staff for their efforts in an email the facility quoted in its state appeal.

“Your staff did an amazing job facilitating one of the most amazing tasks I have ever seen accomplished in my 23 year career!” Sorensen wrote to an employee who worked at the now-destroyed facility.

All long-term care facilities in California are required by law to have written evacuation plans, updated annually and filed with the state. This includes assisted living facilities and nursing homes. But when the Eaton and Palisades fires tore through the region, many of those plans were outdated or failed to identify clear procedures, transportation plans and relocation sites.

LAist reviewed more than 70 plans filed with the state by residential care facilities in L.A. County that were evacuated during last year’s fires. We found over 90% were outdated. Over one-third were last approved a decade ago or longer despite a state law that requires yearly reviews and up-to-date plans.

The plan in place at The Terraces when the Eaton Fire hit had been last approved in 2020, according to state records. Operators assigned evacuation duties — including transportation, head counts and notifying families — to staff members by name.

The plan also identified two nearby facilities as temporary relocation sites: Two Palms Care Center and Pasadena Park Health and Wellness Center, both in Pasadena. On Jan. 7, neither facility was an option. They, too, were under evacuation orders. Two Palms eventually burned down. Pasadena Park was damaged by the Eaton Fire and remains closed.

Rachel Tate, who oversees the L.A. County ombudsman program for long-term care facilities, said many assisted living and nursing homes craft plans for smaller emergencies — like those that involve only one facility, not hundreds.

“I don't think that facilities in Los Angeles County were braced the way they should be for regional incidents where so many people were impacted at the same time,” she said.

The Terraces plans to rebuild and reopen in 2027, according to public statements by the facility’s former community director.

Over the summer, state authorities ordered The Terraces to submit a written plan to update their emergency disaster procedures to avoid fines.

A representative for The Terraces provided LAist a copy of the documents submitted to state authorities in August after the citation. They outline some evacuation procedures including transportation logistics, confirming residents locations and communicating with family members during emergencies.

Diversified Health Services Inc., the Oakland-based company that owns and operates The Terraces, also owns and runs the Gardens at Park Balboa assisted living facility in Van Nuys. The Terraces’ new emergency plan lists the Van Nuys facility, about 30 miles away, as its single temporary shelter location.

A representative for The Terraces said in an email that they will update the plan with more details once the facility is rebuilt and restaffed.

Dorothy Benesh’s evacuation 

Jim Benesh called his mother repeatedly between about 6:45 p.m. and 8:40 p.m. on the evening of Jan. 7, Benesh told LAist. He also tried to call The Terraces directly, he said.

“The reason I didn’t go over there immediately is because my mom said the alarm was going off and she was supposed to stay in her room,” Benesh told LAist.

He said he drove to The Terraces, walked through the building’s glass doors around 9 p.m. and then upstairs to his mother’s room. He said all the doors he saw were wide open aside from room 315, which belonged to his mother.

“My mom was sitting on her couch,” Benesh said. “I told her we needed to move immediately.”

Using his cellphone for light, Benesh said he carried his mother, then 96, and her walker down three flights of stairs. They exited the building at around 9:15 p.m, according to Benesh.

Benesh could not immediately provide LAist with phone records that corroborated his timeline, explaining that they were no longer saved on his phone or by his phone company.

Benesh said two paramedics helped transport him and his mother back to his parked car, but he was unable to determine what agency they worked for.

Khalifa, The Terraces’ CEO, told LAist he believes the timeline of Jim Benesh’s story is not correct. By 9:15 p.m., firefighters had been at the facility for nearly an hour and the building was fully engulfed in flames, Khalifa said in a statement.

“The confirmed factual timeline does not support that account,” Khalifa wrote.

Benesh disputes this.

“But it did happen,” he told LAist this week. “He wasn’t there. And none of the people he claims were trying to get in between 8:45 and 9:15 were there."

"I don’t hold a grudge against The Terraces, I just want to make sure proper protocols are in place so this doesn’t happen again," he continued.

The remains of The Terraces at Park Marino — an assisted living facility that burned in the Eaton Fire.

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Allen J. Schaben

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Los Angeles Times via Getty Images

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State authorities investigated the claim about Benesh’s mother but were unable to substantiate it, according to initial findings in May. They concluded that Benesh’s version of events could be accurate, but without witnesses there was no way to confirm it.

In August, the state Department of Social Services removed the May report from the website where it tracks complaints and citations. A new report posted that month found The Terraces had failed to remove a different resident during the evacuations — the woman in room 326. The second report didn’t change the state’s findings about Dorothy Benesh, which remain unsubstantiated.

In November, The Terraces filed a revised appeal accusing the state of violating public records laws by initially deleting its original May report, rather than keeping both versions on the website. The facility argued in that appeal that the second report from state authorities left out key information and failed to record any new findings about the first complaint about Dorothy Benesh.

“This substitution created confusion in the public record,” the appeal said.

As of this month, the removed report had been restored on the California Department of Social Services’ website. Both reports are now visible to the public.

This reporting was supported by the Fund for Investigative Journalism. None of our funders have any influence on our editorial decisions.