577000881-5-14-2025-21-AS-KMOA-DGVQ53-20250521115115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 05/01/2025
Date Signed: 05/14/2025 10:07:10 AM

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
04/21/2025 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20250421135045

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	CAROL DOWELL		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS: 155	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	04:56 PM
MET WITH:	Carol Dowell		TIME COMPLETED:	04:57 PM

ALLEGATION(S):

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Licensee does not ensure that resident's room is kept in a clean condition.
Licensee does not ensure that facility is not odiferous.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 05/01/2025 to continue the investigation and deliver findings regarding the above allegations. LPA met with Administrator Carol Dowell.
The complaint alleges that Licensee does not ensure that resident’s room is kept in a clean condition and that Licensee does not ensure that facility is not odiferous. It is alleged that R1’s carpeting was saturated with blood and urine and that the room smelled of urine. LPA conducted an inspection of nine (9) resident rooms and found that two (2) of the nine (9) rooms were malodorous and had stains on the carpeting.
Continued on 9099-C

Substantiated

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: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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 4

Control Number 21-AS-20250421135045

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: 05/01/2025

NARRATIVE

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Continued from 9099...

Based on LPA’s observations, the preponderance of evidence standard has been met, therefore the allegations that Licensee does not ensure that resident’s room is kept in a clean condition and Licensee does not ensure that facility is not odiferous are SUBSTANTIATED.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Assistant Administrator.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20250421135045

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: 05/01/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/01/2025 Section Cited CCR 87303	1 2 3 4 5 6 7	87303 Maintenance and Operations:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Licensee agrees to clean carpeting and provide pictures of the cleaning/repair or replacement of the carpeting in affected rooms.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on LPA’s observation of stains in carpet and strong urine smell which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
04/21/2025 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20250421135045

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	CAROL DOWELL		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS: 155	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	04:56 PM
MET WITH:	Carol Dowell		TIME COMPLETED:	04:57 PM

ALLEGATION(S):

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9

Licensee does not ensure that staff meet resident's hygiene needs.

INVESTIGATION FINDINGS:

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The complaint alleges that Licensee does not ensure that staff meet resident’s hygiene needs. R1 was receiving care from the facility staff and outside agency. Based on interviews conducted, review of records, and observations made R1's care needs were being met. Although the allegations may have happened, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

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: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4