When the Eaton Fire reached the backyard of the MonteCedro retirement community in the early hours of Jan. 8, many residents woke up to the smell of smoke and the sound of people knocking on doors.

Residents waited for directions on what to do. Should they shelter in place? Should they head for the exits?

Some told LAist later that they figured staff at the Altadena facility would take the lead. But something went wrong. The retirement community is among the region’s most upscale — the average entrance fee is around $1 million, according to public finance documents.

“We assumed that there’s some kind of plan, but I never saw it, and didn’t think to investigate it when I moved in,” said Linda Bergthold, an 84-year-old who lives at the care facility.

She was among the residents moved to safety during the fire.

According to state authorities, two women were left behind during the dawn evacuations of nearly 200 residents.

Los Angeles County sheriff's deputies found both women at the property hours later. One was walking her dog outside the building's entrance as nearby houses burned. The other, Jean Bruce Poole, then 100 years old, was wandering the dark hallways of the third floor, according to the Sheriff’s Department.

“I think there could be some protocols put in place that they would know who's where and who's not accounted for,” Poole’s son, John Ward, told LAist.

The California Department of Social Services, which licenses residential care facilities, including assisted living facilities, cited MonteCedro in September for failing to follow its own emergency evacuation procedures and leaving residents behind during evacuations.

Neither MonteCedro, nor the nonprofit Episcopal Communities & Services that runs it, responded to multiple interview requests for this story.

In a Jan. 29 statement, Episcopal Communities & Services said that fire personnel and MonteCedro staff “made two complete tours through the building, triggering fire alarms and inspecting every residence.”

“However, two independent living residents were not encountered and did not make it to the buses," the statement read.

At least one other residential care facility, the Terraces at Park Marino in Pasadena, also was cited for not evacuating all residents.

MonteCedro withstood the Eaton Fire. The Terraces did not. The facility was destroyed shortly after firefighters rescued a woman from the third floor who was initially left behind during the evacuations.

Both facilities have appealed the citations, according to state records. MonteCedro’s appeal has not been made public. Administrators for both facilities avoided fines by submitting required plans to fix the problems.

MonteCedro administrators said at a meeting with residents in February that they were working alongside first responders and weren’t the only responsible party, according to a recording of the gathering reviewed by LAist. Administrators noted that the two women who were left behind ended up being moved to safety.

Sheriff’s deputies and Pasadena public transit bus drivers worked with MonteCedro staff to relocate residents to the evacuation shelter at the city’s convention center. One night earlier, the Pasadena Fire Department helped evacuate the Terraces.

Both evacuations reveal what can happen at long-term care facilities during a disaster when emergency planning and coordination are found to be inadequate. They also raise questions about where a facility's responsibility ends and first responders’ begins.

State investigators determined that MonteCedro’s executive director, David Weidert, was designated to remain on site during emergencies, but he went home before the fire closed in on the facility. He also failed to call in additional staff despite emergency protocols requiring it, according to the state’s investigative report.

Weidert has since left MonteCedro. Shortly after residents returned in March, an interim executive director was named, according to the facility’s final public fire update on March 11. LAist made several attempts to reach Weidert by phone and email but was unsuccessful.

State licensing authorities also found that four of the five people working the early hours of Jan. 8 had never been trained in emergency procedures.

Some residents say they have seen safety changes within the past few months.

A day after the Eaton Fire devastated the area, MonteCedro's Facebook page posted an exterior shot of a main building, noting the interiors still needed to be inspected.

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MonteCedro via Facebook

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Hour by hour at MonteCedro

The official evacuation order for the area that includes MonteCedro was issued at 5:42 a.m. on Jan. 8, according to archived alerts from the L.A. County Office of Emergency Management.

By then, the fire had been burning for more than 12 hours.

Bergthold, who has lived at the facility for seven years, said her daughter called her from Los Feliz the night of Jan. 7 to warn her about intensifying winds and encourage her to prepare for a possible evacuation.

Bergthold packed a go-bag and slept in her clothes inside her apartment.

She said that when she woke up the next morning, the smoke outside was so thick she couldn't see the trees outside her window.

"But I was not told to pack any sort of suitcase by the facility," she said. "I was being proactive. I really wanted to be ready, and I'm glad I was."

Weidert, MonteCedro’s then executive director, left the facility Jan. 7 around 10 p.m., according to statements he made at a post-fire town hall meeting in February with residents and their family members.

By that time winds in the area were at 70 mph, and both the Palisades and Eaton fires had been burning for hours.

According to the state investigation, five employees stayed on the clock past 10 p.m.: a building and safety manager named Bruno Molina, a security guard, two caregivers, and one licensed vocational nurse who was a temporary worker.

Molina did not respond to LAist’s interview requests.

Only the managers and administrators at MonteCedro had gone through emergency training. All but one of them had gone home for the day.

At 11:30 p.m. on Jan. 7, the executive director called the facility and told Molina that MonteCedro should shelter in place while awaiting official evacuation orders from county authorities, according to the state’s report.

At the town hall, James Rothrock — CEO of Episcopal Communities & Services, the nonprofit that runs the facility — explained the buildings were built to withstand wind and fire, and that evacuating hundreds of residents too soon could have exposed them needlessly to trauma and other health risks.

“The safest place we want to be was inside the building,” he said. At 3 a.m., MonteCedro staff called the Los Angeles County Sheriff’s Department for help, according to the state investigation.

Around 4 a.m., the Sheriff’s Department and L.A. County Fire Department got involved with the MonteCedro evacuation, according to an Eaton Fire response after-action report commissioned by the county.

At 4:15 a.m., MonteCedro authorities made the decision, along with the L.A. County Fire Department, to evacuate 195 residents who had not previously left on their own, according to a Jan. 29 statement from Episcopal Communities & Services.

Around 5:30 a.m., the evacuation began, according to the state report. By that time, eyewitnesses told LAist they saw fire near the back of the MonteCedro property — and neighboring buildings burning.

Most of the residents, some barefoot and in nightgowns, were rushed outside and onto buses by first responders and facility staff.

Two people were missing.

“That should not have happened,” Rothrock said, in the February town hall recording reviewed by LAist.

He stressed that staff members were working alongside sheriff’s deputies, paramedics and firefighters during the chaos.

Rothrock did not respond to interview requests.

Evacuation plans

During the Eaton and Palisades fires, more than 3,000 residents at more than 100 facilities across L.A. County had to be relocated, according to state authorities.

All residential care facilities are required by law to have written evacuation plans, updated annually and filed with the California Department of Social Services.

LAist reviewed copies of plans for more than 70 assisted living facilities evacuated in January, obtained through a public records request. More than 90% of those plans were outdated. And more than one-third of the facilities’ plans were last updated a decade ago or more, despite state law that requires they be filed each year, updated as needed and approved and checked during annual licensing visits.

Disability policy consultant June Isaacson Kailes reviewed LAist’s findings, as well as dozens of plans independently, and said she was “floored by the inadequacy.”

“Some of them were 10 years old,” she said. “Some of them were not fully filled out.”

MonteCedro’s emergency plan, which was signed and approved by the executive director in 2023, set a framework for what should happen during an evacuation, but state investigators said it lacked details about designated staff roles.

It did not list specific transportation plans or relocation sites as required by state law, according to LAist’s review of the document.

And MonteCedro did not follow some of what it had put in writing, state investigators said in the report. For example, the facility’s plan requires it to maintain an emergency contact list for off-duty staff who are supposed to be called in for help during an evacuation. MonteCedro had no such list, investigators said.

Rachel Tate, who oversees the L.A. ombudsman program for long-term care, said many facilities craft their plans for an emergency that’s just affecting their own location.

“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.

Tate said she encourages families to ask residential care facilities or skilled nursing facilities about their emergency plans.

Isaacson Kailes said local officials should do the same.

“Local governments need to recognize that their plans are weak and inadequate, and therefore they need to be planning with these places," Isaacson Kailes said. “Otherwise, people will die.”

John Ward and his mother, Jean Bruce Poole, celebrating her 100th birthday.

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Courtesy John Ward

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‘Don’t lose me’

By 7 a.m., most of the MonteCedro residents had arrived at the Pasadena Convention Center, which was operating as an evacuation shelter during the fires.

Jean Bruce Poole had not.

She woke up that morning at the care facility and went about her normal routine, her son told LAist. He said she told him she ate breakfast and took a shower before leaving her room. Then she realized the hallways were dark.

The elevators were down. Emergency lights were out. Sheriff’s deputies found her in a hallway hours later, after first spotting another resident walking a dog near the entrance shortly after 9:30 a.m.

Back at the convention center, MonteCedro staffers were doing a head count around that time, according to the account dated Jan. 29 and posted on their website.

Deputies searched the building looking for anyone left behind, kicking down about 40 doors. They found Poole on the third floor, looking for an exit just before 10:30 a.m., according to timestamps on a deputy’s body-worn camera footage. (The footage obtained by LAist above contains text added by the Sheriff's Department.)

“Don’t lose me,” Poole says in the video.

After Rothrock, CEO of the nonprofit that runs MonteCedro, learned two residents were missing, he went to MonteCedro “immediately,” where he was told that two people had been found and transferred, according to the January statement.

Poole was taken to the convention center and then temporarily relocated to Mt. San Antonio Gardens, a care center in Pomona. Eventually she returned to MonteCedro, where she continues to live, her son said.

Ward said his mother didn’t know how close the Eaton Fire had come until she rounded the corner in a patrol car and saw a nearby church in flames.

Pasadena Transit buses arrived at the MonteCedro retirement community in Altadena before dawn on Jan. 8

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Courtesy of a MonteCedro resident

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Looking back, he told LAist, he has some regrets. He said his mother adores MonteCedro — the gourmet meals and access to field trips and concerts. But when it came to safety in an emergency, staff weren’t adequately prepared, he said.

He remembered that his wife told him the previous evening to drive to the care facility to pick up his mother. At the time, the fire was still 3 miles away, and he thought it would never reach her.

“That was a mistake I made,” Ward said. “And it could have been a very serious ending.”

MonteCedro residents and family members told LAist they’re grateful to facility staff who did stick around to help get most people out. That included Molina, the building manager, who they say evacuated residents as his own family home burned down.

“It's extraordinary courage and dedication to us for them to do that,” said Bergthold, the 84-year old MonteCedro resident.

MonteCedro staff told residents they hired a company called Fire & Life Safety Inc. to review its emergency plans and response effort, according to the recording reviewed by LAist. Staff at the meeting said they have no plans to release those findings publicly.

Residents and family members compiled their own list of changes they are demanding from the facility, according to interviews with LAist. The list includes upgrading alarms, new evacuation protocols, more training for staff and better notification systems for residents and families.

So far, residents said MonteCedro has made some of the changes.

Weidert, the previous executive director, retired in February.

The MonteCedro nursing home survived the Altadena fire but residents were evacuated in the middle of the night.

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Aaron Schrank

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LAist

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The facility hired a new executive director, Adam Peña, in August. Bergthold served on a resident committee that hired the new director.

She said that since he took over, there have been new earthquake drills at the facility, residents were provided emergency go-bags with flashlights and battery packs, and a new resident emergency planning committee was created.

Each floor of MonteCedro’s various buildings now have designated emergency leaders, responsible for coordinating evacuations, Bergthold said.

"I'm very pleased with the actions they've taken," she said.

But she and others say there is still work to be done. They’re hoping for a warning system with flashing lights to help people who are visually impaired.

And they want a stronger transportation plan for evacuating residents from the MonteCedro’s memory care villas so residents don’t have to rely on first responders.

Mostly, they want clearer communication from the people in charge, they said.