OAKLAND — In September 2015, a Station 5 firefighter found an alarming situation at a halfway house on San Pablo Avenue and sent a referral to inspectors to visit the three-story building.

Or so he thought.

In fact, the dangerously unsafe building would not be brought to the fire prevention bureau’s attention until 16 months later. An inspection was finally completed March 24 — finding a number of serious violations in the transitional housing facility — and three days later four people were killed in a predawn fire that broke out in a room lit by a candle, according to the preliminary fire investigation.

In another example of the city’s failure to respond appropriately to fire safety issues, the firefighter in September 2015 checked the “referred” box on the department’s inspection software OneStep, but made the critical mistake of not also phoning or emailing the Fire Protection Bureau to alert them that an inspection was needed. That mistake, which has been an issue in the department, according to exclusive emails obtained by this news organization, sent the referral falling through the cracks.

“Clicking that doesn’t do anything on the other end” to send an alert, said Mark Hoffmann, co-acting fire chief, referring to the “referred” box in OneStep. A spokeswoman for Mayor Libby Schaaf confirmed the referral procedure was not followed.

In an exclusive interview with this newspaper Tuesday, Assistant Fire Marshal Maria Sabatini found ample problems when they finally walked through the building on March 24 and ordered extension cords and other wiring removed from the second-floor room where the fire originated, raising the possibility that the resident in that room was using a candle because electricity was no longer available.

“That might have been the case,” Sabatini said, referring to the need to use a candle that apparently started the fire. That question and whether the extension cord was later disconnected will probably be part of the ongoing investigation into the fire, she said.

Tuesday’s revelations show further confusion between the city’s firefighters and the civilian inspectors who have split responsibilities on monitoring fire safety issues inside Oakland’s buildings.

Fire inspection data shows that firefighter Charles Gresher on Sept. 17, 2015, attempted to refer problems at 2551 San Pablo Ave. to the Fire Prevention Bureau. Gresher declined to comment Tuesday and a request for comment from the firefighter’s union was not immediately returned.

On Jan. 11, 2017, Fire Capt. Sean Laffan emailed Sabatini, other inspectors and firefighters, reminding them that the halfway house had been referred to inspectors in 2015 because firefighters believed it was a care facility, needing state-mandated annual inspections by civilian inspectors. Laffan remarked in the email that the building “far exceeds the level of training for a company officer.”

Sabatini, who only moved to her fire marshal role in January after serving for years as an arson investigator, responded the next day to Laffan and a battalion chief, reminding them of firefighter lapses in how referrals are made.

“I’ve learned some (firefighters) think that when the ‘referred’ tab is clicked in OneStep, that an inspector is automatically notified. (This is not true),” she wrote. “Do you think it means someone picked up the phone and called the (Fire Protection Bureau), or sent an email? Not looking to hang anyone here, just really trying to figure out how to smooth this out.”

In the missive she explained the frantic atmosphere in the inspection bureau post-Ghost Ship, and said she had trouble even talking to Fire Marshal Miguel Trujillo because they were so busy and overwhelmed.

“I’m serious … it is crazy busy here,” she wrote. “They are not able to keep up with their own assignments and on top of that, everyday a batch of notices like this situation with 2551 San Pablo comes in.”

The city also provided a timeline by Inspector Flanoy Garrett and his five attempts between Feb. 25 and March 24 to get the building owner or nonprofit tenant to accompany them for an inspection of the three-story apartment building. Finally, part-owner Monsa Nitoto joined them for the inspection March 24.

“When the inspector was finally able to have the reluctant owner appear for the site visit, he was presented with violations to mitigate immediately, and informed that an inspector would return after the weekend to evaluate the progress,” Sabatini wrote in an email Tuesday to city spokeswoman Karen Boyd, obtained by this newspaper. “As part of the inspection we knocked on doors and entered several individual rooms to look for candles and other imminent fire hazards. We entered the room where the fire eventually started, and we spoke with the occupant. There were no candles or careless use of smoking materials observed in any of the rooms.

“I know this awful tragedy cannot be undone but I hope that there might be some awareness that despite a tremendous shortage of inspectors, corrective action was taking place in an attempt to address the safety issues,” she continued.

Also on Tuesday, city officials finally released the December National Fire Protection Association report on the Ghost Ship fire which this newspaper had requested repeatedly since the agency met with Oakland officials a week after the Fruitvale fire in which 36 people died.

The NFPA recommended the city conduct a survey of all occupied buildings and log each one into a centralized database that can be accessed by multiple city departments. The city should use that database to identify the highest-risk properties, set a schedule for inspections and staff the city’s Fire Prevention Bureau appropriately, the group suggested.

The recommendations also encourage the city to identify how property data maintained by different city agencies can be shared and made interactive so employees can more readily access information from other departments.

Last week, the city announced it would be roughly doubling the fire inspection staff, which currently stands at five, and taking steps to enhance their training. The announcement followed the release of emails showing that firefighters — on at least three occasions since the start of this year — urged their bosses to contact the Fire Prevention Bureau and shut down a San Pablo Avenue property.

When it comes to figuring out what to do with known problem properties, however, the recommendations are less clear. The NFPA suggested the city work with city and county staff, along with community members, to develop a policy to assess and address hazardous buildings and also conduct a workshop on how to identify, prevent and intervene in unpermitted social gatherings.

Finally, the NFPA recommended the city do a better job of communicating with just about everyone, from elected officials to city staff and from property owners to the public.