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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 06/22/2020
Date Signed: 06/24/2020 04:42:53 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2020 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200206094154
FACILITY NAME:ATRIA COVELL GARDENSFACILITY NUMBER:
577000881
ADMINISTRATOR:KELLY FREDRICKSONFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: DATE:
06/22/2020
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Ashlee SloanTIME COMPLETED:
12:24 PM
ALLEGATION(S):
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Staff restrained resident to a bed.

INVESTIGATION FINDINGS:
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Amended

Licensing Program Analyst (LPA) Walters conducted a complaint investigation regarding the above allegations. Today’s visit was completed virtually by tele-visit with the Executive Director, Ashlee Sloan, due to COVID – 19 precautions. During this investigation, LPA toured the facility, interviewed residents, staff, and various outside parties, reviewed resident records, staff records and facility records.

Based on interviews conducted 2/18/2020 & 2/21/2020 as well as a review of records LPA learned that the incident occurred approximately 2 years ago and involved 1 of 1 resident (R1) who was tied up while in bed by a former staff (S1). LPA determined that this incident had previously been self-reported by the facility, was investigated and cited by this department on 3/22/18.

Continued on 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20200206094154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ATRIA COVELL GARDENS
FACILITY NUMBER: 577000881
VISIT DATE: 06/22/2020
NARRATIVE
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Based on several interviews conducted and record reviews, LPA was unable to identify any witnesses and there have been no further reports of improper restraints since this incident, therefore this allegation has been determined to be unsubstantiated based on the current investigation.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. No citations issued for this complaint.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2