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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:43:07 AM

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:EMILY, VENEGASFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: 133DATE:
11/19/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Giam Alviedo, Resident Service DirectorTIME COMPLETED:
11:42 AM
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Licensing Pogram Analyst Jill Nakagawa arrived unannounced to do a Case Management Health Check regarding resident R1.

DB has had multiple Incident Reports regarding an ongoing pressure ulcer concern. Current information from Home Health, Accent Care registered nurse, reports that as of 11/17/2021 the pressure ulcer is no longer open. Assessment indicates skin within normal range.

Resident Service Director, Giam Alviedo, will continue to follow resident's progress with Accent Care Agency and their reports/observations to facility. At this time, there are no new concerns.

Exit interview conducted with Resident Service Director, whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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