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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 06/16/2022
Date Signed: 06/16/2022 10:36:09 AM


Document Has Been Signed on 06/16/2022 10:36 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: DATE:
06/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Emily Venegas, Administrator and
Jake Bruno, LVN, Resident Services Director		TIME COMPLETED:
10:45 AM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to Atria Covell Gardens on 6/16/2022 at approximately 9:05 AM to conduct a case management inspection. LPA met with administrator, Emily Venegas and the new Resident Services Director, Jake Bruno, LVN. Administrator submitted incident report on 05/24/2022, reporting a medication error. Fortunately, there were no ill effects. Re-training and corrective action was taken with the employee.

LPA and administrator discussed medication error. Training and testing will be conducted involving all Med. Technicians. Training materials will be supplied by the corporate office and trainings will be carried out by Jake Bruno, LVN, and Administrator, Emily Venegas. Tests will be administered and a passing grade of 90% will be required. All Med Techs will then be evaluated by the new Resident Services Director, Jake Bruno, LVN. Tests and Evaluation forms for each Med Tech. will be submitted to LPA, documenting training and qualifications of each employee performing the role of Medication Technician.

No deficiencies cited during this inspection.

Exit interview conducted with administrator and a copy of this report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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