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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000881
Report Date: 02/03/2026
Date Signed: 04/17/2026 10:04:35 AM

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
02/02/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260202132423
FACILITY NAME:ATRIA COVELL GARDENSFACILITY NUMBER:
577000881
ADMINISTRATOR:KARRIE SILVEYFACILITY TYPE:
740
ADDRESS:1111 ALVARADO AVETELEPHONE:
(530) 756-0700
CITY:DAVISSTATE: ZIP CODE:
95616
CAPACITY:210CENSUS: 173DATE:
02/03/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Karrie Silvey, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not ensure medications are dispensed as prescribed.
Facility did not ensure adequate care and supervision.
INVESTIGATION FINDINGS:
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This report has been AMENDED and reviewed with Administrator Rick Ziese Dulay.
At approximately 09:20 AM on 02/03/2026, Licensing Program Analyst
Licensing Program Analyst(LPA) Jill Nakagawa arrived unnannounced for the purpose of opening a complaint investigation regarding the above allegations.

LPA conducted interviews, requested records and made observations. LPA met with Karrie Silvey, Administrator to review the allegations.

The complaint alleges that Staff do not ensure medications are dispensed as prescribed and Facility did not ensure adequate care and supervision. The complainant stated that they received a call reporting that the facility had been short-staffed and residents were not receiving their medications on time due to a shortage of medication technicians.

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

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
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-20260202132423
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: 02/03/2026
NARRATIVE
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Continued from 9099....

AMENDED: LPA Nakagawa met with Administrator Rick Ziese Dulay and reviewed the amendment.

On 02/03/2026 LPA spoke with Administrator Karrie Silvey who stated that the facility had been on lock down over the past week due to a Gastro-Intestinal Outbreak, which also affected staff, including several medication technicians. LPA requested Medication Administration Records (MARs) and found documentation showing that on 01/29/2026 and 01/30/2026 medications for 27 residents were not given as ordered by the Physician due to administration after the prescribed time. LPA also reviewed the staff schedule for the same dates, 01/29/2026 and 01/30/2026 and found that three (3) medication technicians had called off due to illness. The Administrator and two (2) Directors who had training in medication administration were able to help fill some of the gaps. Records indicate that the added personnel were able to provide the necessary support to administer the medications within a reasonable amount of time and as prescribed. Staffing levels were stretched but staff was able to provide medication management in a timely manner. Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegations Staff do not ensure medications are dispensed as prescribed and Facility did not ensure adequate care and supervision are UNSUBSTANTIATED. Although the allegations may have occurred there is not a preponderance of evidence therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and appeal of rights provided.

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

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260202132423
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: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/03/2026
Section Cited
CCR
87465(c)(2)
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 87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by:
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Administration to submit written plan which addresses how facility will ensure compliance with 87465(c)(2) going forward. To be submitted to CCL by POC date of 02/04/2026 in order to clear the deficiency.
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Based on review of medication administration records of 01/29/2026 and 01/30/2026 the facility did not give medications according to physician's orders. This is an immediate risk to residents in care.
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Deficiency Dismissed
Type A
02/03/2026
Section Cited
HSC
1569.2(c)
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(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications...This requirement was not met as evidenced by:
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Administration to provide a written plan to maintain compliance during epidemic outbreaks or other episodes of multiple staff call offs or shortages by Close of Business on 2/4/2026 to CCL.
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Based on the review of medication administration records (MARs) for 1/29/26 and 1/30/26 administration did not have enough staff to provide adequate care and supervision during medication administration.
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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: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3