577000881-10-1-2021-21-AS-BMOS-C7JUNU-20211006154431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 09/30/2021
Date Signed: 10/01/2021 10:10:53 AM

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
05/17/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210517085947

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	SLOAN, ASHLEE		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS: 134	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Emily Venegas - Executive Director		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not adhere to admissions agreement.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Emily Venegas - Executive Director.

On 5/19/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During interviews with complainant and staff on 5/19/2021 and 6/10/2021 including interviews with former Executive Director Ashlee Sloan in both days, LPA learned that individual/visitor for assisted living (AL) resident R1 wasn’t allowed to enter the facility at 4:40 PM on 5/9/2021 – Mother’s Day.
Continue LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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 3

Control Number 21-AS-20210517085947

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: 09/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Admissions agreement signed by resident R1 on 9/8/2017 states on page 9.h that “Termination on Death….Upon your death your personal property may be removed at any time by appointment or between the hours of 9:00 AM and 5:00 PM by your responsible person, by other person(s) whom you have designated in writing in this residency agreement…” In addition, facility mitigation plan under Visitors – COVID Watch states that “schedule family visits limited to 5 family members at a time, restricted to resident apartment, designated common area and/or designated outdoor area.” Facility had no cases of COVID-19 positive at the day & time of visit. Documentation of schedule visits calendar for 5/9/2021 shows that there was 1 visitor in AL at 4:30 to 6:30 PM inside resident’s apartment and another visitation occurred in Life Guidance – Memory Care outside between the hours of 3:00 to 6:00 PM. Furthermore, individual was at the facility to enter resident R1’s apartment since resident had passed away on 5/1/2021. On the same day, per guest sign-in there was a “family moving” for resident R2 who stayed from 2:37 PM until 5:00 PM who wasn’t schedule in the schedule visits calendar. Based on records review and interviews, facility didn’t follow resident’s admissions agreement within regard to “Termination on Death”.

According with complaint allegation "Facility did not adhere to admissions agreement.” there were related observations made during visit. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20210517085947

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 10/14/2021 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507(f) Admissions Agreement. This requirement is not met as evidenced by:Based on documentation review & interviews the facility did not comply with the section cited above in 1 out of 1 resident admissions aggrement	1 2 3 4 5 6 7	Licensee to ensure that facility is in compliance with terms and conditions set forth in admissions agreement. Facility to submit to CCL a self certification that it will ensure compliance with terms and conditions
	8 9 10 11 12 13 14	which poses/posed a potential health, safety or personal rights risk to persons in care.LPA review records &conducted interviews. Facility had no cases COVID-19 positive and individual was at the facility to enter R1’s apartmen who had passed away on 5/1/2021.Admissions agreement signed by resident R1 on 9/8/2017 states on page 9.h that “Termination on Death….Upon your death your personal property may be removed at any time by appointment or between the hours of 9:00 AM and 5:00 PM by your responsible person, by other person(s) whom you have designated in writing in this residency agreement…”	8 9 10 11 12 13 14	that have been stipulated under a Department approved admissions agreement by POC date of 10/14/2021 in order to clear this citation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3