577000881-5-25-2021-21-AS-HDBI-C3UUFJ-20210610153247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 05/25/2021
Date Signed: 05/25/2021 06:52:52 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
09/15/2020 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200915095317

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	ASHLEE SLOAN		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS:	DATE:	05/25/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ashlee Sloan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are not properly storing medication.
Facility failed to report to licensing agency.
Insufficient staffing.

INVESTIGATION FINDINGS:

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On 5/25/2021 Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Complaint visit and met with Executive Director, Ashlee Sloan to deliver findings regarding the above complaint allegation.

During the course of this investigation LPA conducted virtual visits on 9/22/20 and 5/14/21, interviewed staff and residents, made observations, staffing schedule, timesheets and reviewed the following resident records: Charting notes, Physician reports, Care plan’s, Centrally Stored Medication and Destruction report . The following determinations were made:

Continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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 4

Control Number 21-AS-20200915095317

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: 05/25/2021

NARRATIVE

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Continued from 9099

It was alleged that the facility had Insufficient staffing. The complainant alleges that there were not enough staff on duty to support the residents needs in memory care. LPA reviewed facility time sheets and schedules for the week of 8/30-9/5/2020, interviewed staff and reviewed resident records. Per the Administrator, Assisted Living Staff are able to assist memory care staff when a need arises. Based on interviews and a review of facility records, LPA Walters was unable to determine that there was insufficient staffing therefore the allegation is UNSUBSTANTIATED.

It was also alleged that the- Facility failed to report to licensing agency. The complainant alleges that the facility was not reporting reportable incidents to to Community Care Licensing. Based on a review of incident reports provided by the facility, Resident Care plans and charting notes. LPA was unable to determine that the facility did not report an incident that threaten the welfare, safety or health of any resident. Therefore this allegation is UNSUBSTANTIATED.

It was also alleged that Staff are not properly storing medications. LPA Walters toured the facility on 9/22/20 and observed that all medication was properly stored in the medication room. Medications that were to be destroyed were stored in the cabinets of the medication room. In addition, LPA interviewed Executive Director and Staff who were unaware of medications being stored elsewhere. Based on interviews with staff, and LPA's observations, LPA was unable to corroborate the allegation occurred. Therefore allegation is found to be UNSUBSTANTIATED

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
09/15/2020 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20200915095317

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	ASHLEE SLOAN		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS:	DATE:	05/25/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ashlee Sloan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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9

Facility failed to observe changes.
Facility failed to report observed changes of condition.

INVESTIGATION FINDINGS:

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13

On 5/25/2021 Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Complaint visit and met with Administrator, Ashlee Sloan to deliver findings regarding the above complaint allegation.

During the course of this investigation LPA conducted virtual visits on 9/22/20 and 5/14/21, interviewed staff and residents, made observations, staffing schedule, timesheets and reviewed the following resident records: Charting notes, Physician reports, Care plan’s, Centrally Stored Medication and Destruction report . The following determinations were made:

Continued on 9099 C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20200915095317

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: 05/25/2021

NARRATIVE

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The complainant alleges: Facility failed to observe changes and that Facility failed to report observed change of condition. More specifically the complainant alleges that the facility has failed to observe changes in R1 and that Staff then failed to report changes in R1's status to their physcian. LPA interviewed staff who confirmed that R1, did have behavioral and physical health changes. LPA reviewed R1's Needs and Service Appraisal which indicates that the facility was aware of the residents change in condition and were providing services. In addition LPA reviewed a fax in which the facility notified the Physician of R1's health changes. Based on the documents reviewed and interviews LPA determined the allegation did not occur Therefore this is allegation is UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Executive Director's signature was not captured. A copy of the report was sent to Administrator.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4