577000881-8-29-2025-21-AS-KMOA-DLUPJ7-20250925112103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 08/29/2025
Date Signed: 08/29/2025 02:20:43 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
04/22/2025 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20250422125218

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: 145	DATE:	08/29/2025
		UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Karrie Silvey, Executive Director		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff implemented a restrictive facility environment for resident in care
Staff mismanaged resident's medications
Staff did not conduct proper admission procedure
Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived unannounced at Atria Covell Gardens on 08/29/2025 at approximately 1:03 PM to conclude an investigation and deliver findings regarding the above allegations. LPA met with Executive Director Karrie Silvey, who allowed access to the facility and provided LPA with requested documentation.

LPA made a tour of the facility, including the dining room, common areas and the Memory Care unit.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

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-20250422125218

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: 08/29/2025

NARRATIVE

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Continued from 9099...
The complaint alleges that Staff implemented a restrictive facility environment for resident in care (R1) and R1’s personal rights were violated. The complainant states that the facility did not allow resident R1 access to the facility and could not leave the facility without family or chaperone. LPA Nakagawa reviewed documentation and found that the facility conducted a 2-week assessment to monitor for safety and level of care of R1; requesting the family provide 24-hour companion care to ensure resident R1’s safety during the assessment period. Administrator stated that during the course of the two week assessment R1 was allowed access throughout the facility, including access to all amenities, programs and interior garden areas. The accessibility of the interior footprint of the facility was never restricted. Access to the exterior of the facility was in accordance with the Physician’s Report of 04/03/2025, which stated that R1 could leave the facility accompanied by spouse, family member or designated staff/chaperone. Companion Care staff (CC1) stated that they were not to be interactive, only monitor and document and were not included in the designated staff (and only there for 2 weeks). On 05/12/2025, R1’s physician wrote a letter stating “R1 was seen on 05/12/2025. R1 may go outside unattended on site anywhere on campus at Atria. R1 may not leave the campus unattended”. Accessibility to the exterior of the facility including sidewalks outside the building was adopted into the Care Plan of R1. Accessibility at the facility was unrestricted; and the resident was not placed in Memory Care. The assessment process included the input from family, physicians, and the facility’s team and assessment tools to ensure that R1’s assessment was thorough and provided the information needed to make a comprehensive decision that would be the least restrictive environment and maintain a safe environment for R1’s placement. Ultimately, accessibility at the facility was unrestricted and R1 was admitted to Assisted Living with spouse. Based on the documentation from the assessment process the allegations that Staff implemented a restrictive facility environment for resident in care and committed a violation of Personal Rights are unsubstantiated. Although the allegations may have occurred, there is not a preponderance of evidence to verify that the allegations occurred therefore the allegations that Staff implemented a restrictive facility environment for resident in care and violated Personal Rights are UNSUBSTANTIATED.

Continued on 9099-C(2)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20250422125218

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: 08/29/2025

NARRATIVE

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Continued from 9099-C

The complaint alleges that staff mismanaged resident’s medications. LPA reviewed medication records for R1 from the date of admission, 04/18/2025 until 07/01/2025 and found no evidence of staff mismanaging R1’s medications. LPA found multiple communications between facility and R1’s doctor regarding medication clarifications and R1’s refusals to take medications. Medication Administration Record (MAR) showed medication refusals by R1 on multiple occasions. MAR showed that refusals for medications were properly documented and internal reports were completed which indicate that the responsible party and physician were notified. Based on the facility’s medication administration records for the months of April, May and June the allegation that staff mismanaged resident’s medications is unsubstantiated. Although the allegation may have happened there is not a preponderance of evidence therefore the allegation that staff mismanaged resident’s medications is UNSUBSTANTIATED.

The complaint alleges Staff did not conduct proper admission procedure. The complainant states that applicant was denied admission to Assisted Living and instead offered residency in Memory Care. LPA Nakagawa reviewed the Licensee’s Program Plan which outlines multiple assessments used to determine a resident’s placement /suitability: Physician’s Reports (602s), assessments such as the SLUMS (The Saint Louis University Mental Status Examination) and observations are used to help determine an individual would be safe in the Assisted Living community and that the facility would be able to meet the resident’s needs. LPA reviewed R1’s assessment process which included three Physician’s Reports (602s). Due to the multiple, contradicting LIC602s received during the admission process the facility conducted a lengthy assessment, which included several assessments as well as a 2-week observation, which required a one-on-one, provided by the responsible party, to verify R1’s safety in the Assisted Living community and that the facility would be able to meet the resident’s needs. With physicians’ reports and assessments completed, R1 was admitted to the least restrictive environment, the Assisted Living community, where R1 resides with spouse.

Continued on 9099-C(3)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20250422125218

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: 08/29/2025

NARRATIVE

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Continued from 9099-C(2)

Based on the program plan, R1’s assessments and multiple Physicians’ Reports the allegation that Staff did not conduct proper admission procedure is unsubstantiated. Although the allegation may have occurred, there is not a preponderance of evidence to verify that Staff did not conduct proper admission procedure, therefore the allegation that Staff did not conduct proper admission procedure is UNSUBSTANTIATED.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

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