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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 01/23/2023
Date Signed: 01/23/2023 03:46:53 PM


Document Has Been Signed on 01/23/2023 03:46 PM - 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:KAWANA ANTHONYFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: 146DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kawana Anthony, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Atria Covell Gardens on 01/23/2022 for the purpose of following-up on an incident report that was self-reported to the CCL Regional Office (RO). LPA was screened following Covid-19 protocols and was granted access into the facility and was met by Administrator, Kawana Anthony.

CCL received an incident report reporting a medication error. The error occurred on 01/17/2023. While S1 was dispensing medication, R1 was given the prescribed medication for another resident. R1's responsible party and prescribing doctor were notified of medication error and R1 was taken to hospital for evaluation. R1 returned to facility with no adverse reactions or change in condition.

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: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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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Document Has Been Signed on 01/23/2023 03:46 PM - 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: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2023
Section Cited

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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 evdenced by:
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Administrator agrees to ensure S1 has additional medication training on the 7 Rights of Medication Administration before passing medication.
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 Based on LPA's record reveiw and interview with staff resident (R1) was given another resident's medications in error which poses an immediate health and safety risk to resident in care.
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Administrator agrees to submit training date to CCL by POC 01/24/23 and the training roster signed by S1 and trainer by 01/25/23.

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
LIC809 (FAS) - (06/04)
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