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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 06/10/2026
Date Signed: 06/10/2026 03:48:44 PM

Substantiated


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
02/25/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260225125201
FACILITY NAME:ATRIA COVELL GARDENSFACILITY NUMBER:
577000881
ADMINISTRATOR:KARRIE SILVEYFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: 149DATE:
06/10/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rick Dulay, AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff did not provide medication assistance to resident in care resulting in hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and to deliver findings. LPA met with Administrator Rick Ziese Dulay to discuss.

The complaint alleges that Staff did not provide medication assistance to
resident in care resulting in hospitalization. LPA reviewed Resident (R1) medication administration records (MAR), Service Plan, and Admission/Lease Agreement. Records indicate that R1physically moved in to the facility on 01/02/2026 and was to receive medication management services as listed on their service plan and assessment dated 12/31/2025.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026
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-20260225125201
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: 06/10/2026
NARRATIVE
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Continued from 9099....

A review of R1’s MAR for January, 2026 shows no recorded medications or medications being administered. R1’s MAR for the month of February, 2026 shows the required medications but does not show that the administration of any medications was given to R1. R1 received multiple assessments from the time of move-in due to a change in condition, but staff failed to look at the administration of medications as agreed to in service agreement. A self-reported incident report by facility on 02/13/2026 states it was discovered on 02/09/2026 that R1 had not received medication since move-in on 01/02/2026. Medical records state that R1 suffered a hyperglycemic event and additional side effects, due to not receiving necessary insulin; which required hospitalization. Based on review of facility records, interviews with outside parties, and R1’s medical records the allegation that Staff did not provide medication assistance to resident in care resulting in hospitalization is Substantiated. Deficiencies cited. (See 9099-D).

An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care based on Regulation HSC1569.269(a)(6).

The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(f), or 1548(e) or (f), 1568.0822(f).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260225125201
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2026
Section Cited
HSC
1569.269(a)(6)
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Health & Safety Code
1569.269(a)(6) Enumerated rights; severability
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met as evidenced by:

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POC: The facility receives training from an outside source/regional office on resident care and coordination with accurate assessments and medication management. A plan for this training to be submitted to LPAby 6/12/2026, with training to be completed by 7/1/2026. Proof of completion to be submitted to LPA by 7/1/2026.



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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3