<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000881
Report Date: 12/03/2020
Date Signed: 12/04/2020 10:36:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GARDENSFACILITY NUMBER:
577000881
ADMINISTRATOR:ASHLEE SLOANFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:210CENSUS: DATE:
12/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Ashlee SloanTIME COMPLETED:
04:30 PM
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
At approximately 4:05 PM on 12/03/2020 Licensing Program Analyst (LPA) K. Walters contacted Executive Director, Ashlee Sloan (ED) by phone for the purpose of conducting a case mangagement. This complaint was conducted by phone due to COVID – 19 precautions, a facility visit is not able to be conducted at this time.

During the course of a complaint investigation, LPA Walters reviewed facility records for R1 and learned that resident’s medication was being crushed by a resident’s private caregiver. Facility assessment indicates that R1 has a caregiver who crushes their medication for them. LPA interviewed staff and other various parties who confirmed that private caregivers were crushing medication for resident, because resident has difficulty swallowing. It was determined that R1 was unable to handle medication on their own and was requiring assistance of their private caregiver, who was not employed by the facility. Therefore the private caregiver was providing care and supervision for R1, which is not allowed by healthy and safety code.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or the Health and Safety Code. (see LIC 809D) Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal right provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2020
Section Cited

1
2
3
4
5
6
7
Health and Safety Code section 1569.2(c) "Care and supervision" means the facility assumes responsibility for..ongoing assistance with activities of daily living..Assistance includes assistance with taking medications.. or personal care.
8
9
10
11
12
13
14
Based on file review and interviews, the Administrator did not comply with the section cited Private Caregiver assisted R1 with medication, which poses/posed a potential 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
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2