577000881-12-15-2023-21-AS-VBEI-CZDVTP-20240111154328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:49:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20231030091516

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	BARBARA FLECK		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS: 143	DATE:	12/15/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Barbara Fleck, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not ensuring resident's medication is being administered as prescribed.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on December 15, 2023 at approximately 12:05 PM to continue a complaint investigation and deliver findings regarding the above allegation.

The allegation states that Staff are not ensuring resident's medication is being administered as prescribed.

Continued on 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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 2

Control Number 21-AS-20231030091516

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/15/2023

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

...Continued from 9099

This investigation has included site visits, interviews and document reviews. The following determinations were made: according to the medication log R1 received medications as prescribed. The complainant reported R1 went to the front desk to report symptoms and questions about medications. Complainant states that they contacted R1's family and staff. . LPA was unable to corroborate complainant's statements with R1's family or staff. Reports from physician state that the medications in question would not have caused the symptoms R1 had Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegations true or false therefore the complaint is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2