Overview
- The 27-page assessment credits firefighters, police and EMS with rescuing 53 residents during the July 13 blaze that killed 10.
- Investigators’ work remains ongoing; the report lists the cause as undetermined with possible ignition from an oxygen concentrator or smoking materials in a second-floor room.
- The fire chief recommends applying nursing-home fire-safety standards to assisted living, group homes, day cares, boarding houses, sober homes and shelters, including regular life-safety inspections.
- Structural issues—including no hallway fire doors or smoke compartmentalization, air conditioners secured with plywood in bedroom windows, and a single elevator—forced many rescues through small bathroom windows.
- Operational fixes proposed include increased staffing and faster mutual aid, radio-based communications, more drills and pre-fire planning, and a support vehicle to refill air cylinders; separate reporting has flagged recalled sprinkler heads at the site and other properties.