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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 05/25/2021
Date Signed: 05/25/2021 06:57:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GARDENSFACILITY NUMBER:
577000881
ADMINISTRATOR:SLOAN, ASHLEEFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: 131DATE:
05/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Ashlee SloanTIME COMPLETED:
04:00 PM
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On 5/25/2021 Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Case Management visit and met with Executive Director, Ashlee Sloan (AS).

LPA Walters conducted a virtual complaint visit at this facility on 9/22/20. On that date, LPA toured the facility virtually, by way of AS and observed a basket of medications in the cabinet of the Memory Care Medication room. Per AS these medications were to be destroyed. (pictures on file).

LPA requested and reviewed the Centrally Stored Medication Logs of the residents whose medication was to be destroyed, The facilities medication destruction policy, along with the pictures of the medications that were to be destroyed. LPA requested that AS provide centrally stored logs and/or orders to destroy medication for R1 and R2. The Administrator was unable to locate documents. AS confirmed that they understand that all records should be accessible for 3 years as required per regulation. LPA learned the following:

Per record review, Resident R1 moved out of the facility on 4/6/2020 and At the time of inspection R1's medication had not been destroyed and was being stored in the facility as of 9/22/20. Resident R2's moved out of the facility on 7/1/2020 and their medication had not yet been destroyed and was being stored in the facility as of 9/22/20. Upon learning this, AS had all dc'd medication destroyed. LPA conducted subsequent visits on 5/14/21 and 5/25/21 and confirmed that dc'd medications were destroyed within 30 days.

LPA reviewed the facility Medication Destruction Policy, which states that all medications which are no longer in use by the resident will be destroyed.
continued on 809 C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (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.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 809

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.,
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2021
Section Cited

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87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed..Based on observation and interview, the
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Faciltiy did not comply with the section cited. LPA observed that the facility did not destroy 2 residents medications. which poses/posed a potential health, safety or personal rights risk to persons in care.
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Administrator agrees to send LPA Walters self certification by email by 6/1/21.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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