<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:39:35 AM


Document Has Been Signed on 05/24/2022 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 143DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Emily Venegas, AdministratorTIME COMPLETED:
10:45 AM
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
Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Atria Covell Gardens for the purpose of following-up on an incident report that was self-reported to the Regional Office (RO). LPA was met by Administrator, Emily Venegas, and was granted access into the facility.

CCL received an incident report reporting a medication error. The error occurred on 05/03/22 while S1 was dispensing medication, under the direction of S2. R1 was given the wrong prescribed medication during medication passing. R1's. Responsible party and prescribing doctor were notified of medication error and R1 taken to hospital for observation. R1 returned to facility with no adverse reactions. LPA obtained copy of the in-house incident report indicating a medication error.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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 2


Document Has Been Signed on 05/24/2022 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ATRIA COVELL GARDENS
FACILITY NUMBER: 577000881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2022
Section Cited

1
2
3
4
5
6
7
87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14

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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2