CASTRO VALLEY -- A state elder care agency promised reforms as it acknowledged Wednesday it "fell short of its mission to protect the health and safety of residents of Valley Springs Manor" who were left to fend for themselves in October.

Only a janitor and cook stayed behind to care for more than a dozen frail and elderly residents of the Castro Valley assisted living home after the state Department of Social Services ordered its closure without checking to make sure all of the residents found new places to live.

State officials made a "judgment call" that the troubled home could keep running for a few days as the residents moved out, "but that judgment was in error," the agency announced Wednesday in a statement that marked the completion of an internal investigation of how its Community Care Licensing Division responded to the developing crisis.

Alameda County Sheriff’s Department tape is seen in front of he Valley Springs Manor care home on Apricot Way in Castro Valley, Calif., on Sunday,
Alameda County Sheriff's Department tape is seen in front of he Valley Springs Manor care home on Apricot Way in Castro Valley, Calif., on Sunday, Oct. 27, 2013. Residents of the home were evacuated on Saturday afternoon after the facility was shut down and their license was suspended by the California Department of Social Services on Thursday. Only several staff members, including a cook, assistant cook and a housekeeper, remained at the facility until Saturday. (Jane Tyska//Bay Area News Group)

Alameda County emergency crews ordered a mass evacuation of the Castro Valley facility after discovering the residents in deplorable conditions after a series of 911 calls on Oct. 26, two days after state officials revoked the home's license and posted a closure sign on the front door.

The internal review found the state "erred in not ensuring, through successful engagement with local partners, that relocation arrangements for all of the residents were complete. The division also clearly erred in not directing existing staff or deploying additional field staff to remain on site until the transfer of the residents was completed and the facility was closed."

No state workers were fired or placed on leave.

In the days and weeks before the home's license was revoked, Alameda County's Adult Protective Services agency said it never received any communication from the state asking for help transporting the clients to new homes.

The Alameda County Sheriff's Department is investigating the owner of the home, San Leandro resident Hilda Manuel and her family, on suspicion of elder abuse. State officials had been working for months to revoke the home's license and ban Manuel and her daughter from ever running a care home again because of a host of health and safety violations.

The state said Wednesday it is changing and reinforcing some of its policies to ensure residents are not abandoned after a troubled home loses its license. When homes ordered closed, state workers will now have to remain at the home "until relocation is complete."

The state said it is also putting more responsibility on the top official of the Community Care Licensing division to review each emergency closure order and draft a relocation plan. The director who signed off on Valley Springs Manor's license revocation proceedings, Jeffrey Hiratsuka, retired over the summer before the home closed. An interim director now holds the position as the state Department of Social Services and the office of Gov. Jerry Brown search for a permanent replacement.

State Sen. Ellen Corbett, D-San Leandro, said Wednesday she appreciated that the agency plans to take corrective action but she still plans to introduce legislation this year.

Corbett, whose district encompasses Castro Valley, said she wants to further strengthen the inspection process for California's thousands of assisted living homes and lessen the trauma on residents forced to move after an unexpected closure.

"It is unconscionable that over a dozen assisted living residents were left virtually alone for two days at Valley Springs Manor last October with minimal follow-up by the state," Corbett said in a written statement Wednesday.