577000881-9-8-2020-21-AS-HDBI-BV5RNG-20201107121016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 09/08/2020
Date Signed: 09/08/2020 03:36:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2020 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200831111528

FACILITY NAME:	ATRIA COVELL GARDENS		FACILITY NUMBER:	577000881
ADMINISTRATOR:	ASHLEE SLOAN		FACILITY TYPE:	740
ADDRESS:	1111 ALVARADO AVE		TELEPHONE:	(530) 756-0700
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	210	CENSUS:	DATE:	09/08/2020
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Ashlee Sloan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident is not provided adequate food service.
Facility failed to provide adequete supervision, resulting in resident sustaining an injury.
Facility failed to seek timely medical treatment.

INVESTIGATION FINDINGS:

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On 9/8/2020 at 12:36 PM Licensing Program Analyst LPA Walters conducted a complaint investigation regarding the above allegation. The visit was conducted by tele-visit due to COVID-19 precautions. LPA met with Executive Director, Ashlee Sloan.(AS)

During this visit the facility was toured, resident records were reviewed, and interviews were conducted. The complaint alleges that staff did not seek timely medical treatment for resident’s injury. The complaint also alleges that the facility failed to provide adequete supervision, resulting in resident sustaining injury. An incident report and interview with various parties indicates that R1 had an unwitnessed fall. Facility contacted Non-Emergency and had resident assessed on the same day. R1 was transported to the hospital for further assessment. Additionaly, LPA learned through record reveiw that R1's physician report doesn't indicate that the resident needs supervision or assistance.

continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200831111528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ATRIA COVELL GARDENS	FACILITY NUMBER: 577000881
	VISIT DATE: 09/08/2020

NARRATIVE

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An Additional complaint alleges that resident is not receiving food at an adequate temperature. At 12:50 PM LPA toured facility dining area with AS, and observed 2 heating carts and 3 drink carts. AS stated that food and drink items are placed in and on carts, and are delivered individually to residents rooms. Residents can choose drink and food items the day prior by placing an order. LPA learned through a staff interview If residents aren’t able to physically open their doors to receive their meal, staff have keys to their doors and will place their meals on tables. LPA was unable to find any information proving the above allegation.

An exit interview was conducted at 2:59 PM.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No citations cited during today’s visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC9099 (FAS) - (06/04)

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