Inspection Reports for Atria Covell Gardens

The inspection was an unannounced complaint investigation visit conducted to investigate allegations including restrictive facility environment for a resident, medication mismanagement, improper admission procedures, and violation of personal rights.

The investigation found all allegations unsubstantiated based on thorough review of documentation, assessments, medication records, and interviews. The resident's environment was not restrictive beyond physician orders, medications were properly managed with documented refusals, and admission procedures were properly conducted.

The complaint included allegations that staff implemented a restrictive environment for resident R1, mismanaged medications, did not conduct proper admission procedures, and violated personal rights. The investigation concluded all allegations were unsubstantiated due to lack of preponderance of evidence.

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The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.

The inspection found the facility to be in compliance with regulations, including proper storage of medications and toxins, adequate hygiene and food handling practices, and up-to-date fire safety inspections. No citations were issued.

The inspection was conducted to review a Case Management - Incident Report regarding a resident who took a pill found on the floor of their apartment, which could not be safely identified, prompting hospital observation.

The facility conducted re-training with medication technicians on the Six Rights of Medication Administration to ensure proper medication administration. A Type B deficiency was cited for failure to assist residents with self-administered medications safely, based on the incident.

The visit was complaint-related, triggered by an incident report dated 06/08/2025 where a resident took a pill found on the floor. The resident was transported to the hospital for observation and returned the same day. The complaint was substantiated with a cited deficiency.

An unannounced complaint investigation was conducted regarding an allegation that staff did not ensure a resident's room was properly operating.

The investigation found that the resident's air conditioning unit was inoperable but the facility had taken steps to address the issue, including providing a temporary portable unit and scheduling repairs. The allegation was determined to be unsubstantiated due to insufficient evidence.

The complaint was unsubstantiated. The resident reported the broken air conditioning unit multiple times, a work order was filed, and repairs were scheduled. The facility was found to be in the process of making repairs.

An unannounced complaint investigation visit was conducted in response to allegations that the facility did not issue a refund to a resident in care and charged a resident for services not rendered.

The investigation found both allegations to be unsubstantiated. The facility's lease agreement specifies no refunds for absences including hospital stays, and the resident did not provide the required 30-day notice to terminate the lease, making charges for that period valid.

The complaint alleged the facility did not issue a refund to a resident who was hospitalized and charged for services not rendered after the resident moved out due to unmet care needs. Both allegations were found unsubstantiated after review of lease agreements and staff interviews.

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The inspection was an unannounced complaint investigation visit triggered by allegations that the licensee did not ensure that residents' rooms were kept clean, the facility was not odiferous, and that staff met residents' hygiene needs.

The investigation substantiated that some resident rooms were malodorous and had stained carpeting, posing an immediate health and safety risk. However, the allegation that staff did not meet residents' hygiene needs was unsubstantiated based on interviews, record reviews, and observations.

The complaint was substantiated regarding unclean resident rooms and facility odor but unsubstantiated regarding staff meeting residents' hygiene needs.

The visit was an unannounced Case Management visit regarding multiple incidents around resident R1.

The Administrator and staff are monitoring resident R1 for any changes in condition and seeking supports for his care. No deficiencies or citations were issued at the time of the visit.

The inspection was an unannounced annual comprehensive inspection conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, well maintained, and comfortable with no deficiencies or citations issued. Safe food handling procedures were followed, and residents were appropriately cared for with positive feedback from staff and residents.

The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing regulations at the assisted living and memory care facility.

The inspection found no deficiencies or citations. Resident and employee files were complete, medications were properly stored and handled, and all required postings and safety measures were in place.

The inspection was conducted as an unannounced complaint investigation regarding allegations that staff were not providing adequate care and supervision to residents and that the facility was not clean and sanitary.

The investigation found that residents were clean, groomed, and appropriately cared for with adequate staffing observed. The facility was found to be clean, comfortable, and well-maintained. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated complaint.

The complaint alleged inadequate care and supervision of residents, including isolation of Memory Care residents due to a COVID outbreak, and unsanitary living conditions. The complaint was determined to be unsubstantiated based on observations, interviews, and document review.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not ensuring residents' medication was being administered as prescribed.

The investigation included site visits, interviews, and document reviews. It was determined that resident R1 received medications as prescribed, and there was insufficient evidence to prove the allegations true or false. Therefore, the complaint was unsubstantiated.

The complaint alleged that staff were not ensuring resident's medication was administered as prescribed. The investigation found no preponderance of evidence to substantiate the complaint, and it was deemed unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation that staff were not providing food service for the residents, specifically that dining room service was not being provided as of September 12.

The investigation found that the facility was mitigating the spread of Covid-19 by closing communal dining areas and providing tray service to each resident, following guidance from the Yolo County Health Department and infection control regulations. Food service was confirmed to be provided, and the allegation was unsubstantiated due to lack of evidence.

The complaint alleged that staff were not providing food service to residents and that dining room service was not being provided since September 12. The allegation was unsubstantiated after investigation, which included interviews and document review confirming tray service was provided in accordance with infection control plans and health department guidance.

An unannounced complaint investigation visit was conducted due to an allegation that staff mismanaged resident medication.

The investigation found that Resident (R1) was given an additional dose of medication in excess of the physician's order due to a computer system alert error. The allegation was substantiated based on observations, interviews, and record reviews.

The complaint was substantiated. The allegation was that staff mismanaged resident medication, specifically administering an extra dose to Resident (R1) due to a computer system error.

The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing regulations.

The facility was found to be clean, orderly, and well-maintained with no deficiencies or citations issued. Safety equipment and emergency drills were up to date, and the kitchen and dining areas met regulatory standards.

The visit was an unannounced Case Management - Other inspection to review a self-reported SOC 341 suspected abuse report involving a resident and a family member.

No deficiencies were observed or cited during the visit. The incident involved brief verbal abuse by a family member toward a resident, with no physical abuse, and was cross-reported to other agencies.

The visit was complaint-related to a self-reported suspected abuse incident. The report states the mandated reporter heard abusive verbal remarks by a family member toward a resident. The incident was brief with no physical abuse and was cross-reported to other agencies.

The visit was an unannounced follow-up on an incident report self-reported to the Community Care Licensing Regional Office regarding a medication error that occurred on 01/17/2023.

The inspection found that a medication error occurred where one resident (R1) was given another resident's prescribed medication, posing an immediate health and safety risk. The resident was taken to the hospital for evaluation and returned with no adverse effects. A deficiency was cited for failure to assist residents with self-administered medications as required.

The visit was an unannounced Case Management Investigation regarding the theft/loss of a resident's recumbent bicycle and another resident's recumbent bicycle and adult tricycle.

No deficiencies or citations were found or issued during the investigation. The losses were reported to the Davis Police Department and the facility's corporate office.

Investigation was related to theft/loss of residents' bicycles. No deficiencies were found and no citations issued.

The visit was an unannounced Case Management visit conducted to review the facility's reporting guidelines, staff training, and current resident conditions.

The facility was found to be clean and orderly with no Covid-19 cases. Reports were timely and well-written, staff training on medication management was adequate, and no deficiencies or citations were found during the inspection.

The inspection was conducted to check on the new Medication Administration Record (MAR) system and Memory Care at the facility.

The facility was found to be clean, orderly, and in good repair with all amenities operational. Staff and residents were interactive and engaged, and no deficiencies or citations were found during the inspection.

The inspection was a required 1-year unannounced visit focused on infection control procedures and practices at the facility.

The facility was found to be clean, orderly, and compliant with infection control protocols, including visitor and staff screening, proper storage of medications and toxins, sufficient supplies of hygiene products and PPE, and approved plans for dementia care and hospice waiver. No deficiencies or citations were issued during the inspection.

The inspection was conducted as a case management visit following an incident report submitted on 05/24/2022 regarding a medication error.

No deficiencies were cited during the inspection. The facility implemented re-training and corrective action for the employee involved, and plans were made for further training and testing of all Medication Technicians.

The visit was complaint-related due to a medication error incident report. The error had no ill effects, and corrective actions including retraining and testing were initiated.

The visit was an unannounced follow-up on a self-reported incident involving a medication error that occurred on 2022-05-03.

The facility failed to ensure that resident R1 received medication as prescribed, resulting in a medication error that posed an immediate health and safety risk. The resident was taken to the hospital for observation and returned with no adverse reactions. Deficiencies were cited related to medication administration.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-12-16 regarding insufficient staffing and uncomfortable facility temperature.

The investigation found that most call lights were answered within 3-8 minutes, with some taking 12-15 minutes, indicating adequate staffing. The facility temperature was found to be between 74-76 degrees Fahrenheit, comfortable for most individuals. Both allegations were unsubstantiated and no deficiencies were cited.

Complaint alleged insufficient staffing resulting in care needs not being met and that the facility was not a comfortable temperature. The allegations were found to be unsubstantiated based on observations, interviews, and record reviews.

The inspection was an unannounced Case Management Health Check regarding resident R1, focusing on ongoing pressure ulcer concerns.

The pressure ulcer for resident R1 was reported as no longer open as of 11/17/2021, with skin assessment within normal range. No new concerns were identified and no deficiencies were cited during the inspection.

Unannounced complaint investigation visit conducted due to an allegation that the facility bathroom was not kept clean.

The inspection of two facility restrooms found them clean with no offensive odors and adequate toiletry supplies. Trash cans were not empty but not overflowing. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility bathroom was not kept clean. The investigation found no evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The inspection was an unannounced complaint investigation triggered by an allegation that the facility did not adhere to the admissions agreement.

The investigation found that the facility did not comply with the admissions agreement regarding termination on death and visitor policies, specifically related to a resident who had passed away and the handling of personal property and visitation. The allegation was substantiated based on documentation review, interviews, and observations.

The complaint was substantiated. The allegation was that the facility did not adhere to the admissions agreement, specifically regarding termination on death and visitor access. The investigation included interviews, documentation review, and observations conducted on 5/19/2021 and 6/10/2021, with findings supporting the complaint.

The inspection was an unannounced complaint investigation triggered by allegations that the facility failed to provide residents with food of good quality and that the Administrator did not treat residents with dignity and respect.

The investigation included interviews, documentation review, and facility observations. The allegations regarding food quality and administrator treatment were found to be unsubstantiated due to insufficient evidence to prove or disprove the claims. No deficiencies were cited during this inspection.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included poor food quality and lack of dignity and respect from the Administrator.

An unannounced Annual Inspection focusing on Infection Control was conducted to evaluate the facility's compliance with health and safety standards.

The facility was observed to be clean, well-maintained, and compliant with infection control protocols including COVID-19 vaccination and mask usage among staff. No deficiencies were cited during this inspection.

The visit was an unannounced Case Management visit conducted to follow up on medication destruction practices and compliance with facility policies.

The facility failed to destroy medications of two residents who had moved out months earlier, posing a potential health and safety risk. The administrator subsequently destroyed the medications and agreed to submit a self-certification. Deficiencies were cited related to medication destruction policy compliance.

An unannounced complaint investigation visit was conducted in response to allegations received on 09/15/2020 regarding improper medication storage, failure to report to licensing agency, and insufficient staffing at the facility.

The investigation found all allegations to be unsubstantiated after reviewing records, interviewing staff and residents, and making observations. No deficiencies were cited during the inspection.

The complaint alleged that staff were not properly storing medication, the facility failed to report incidents to the licensing agency, and there was insufficient staffing to meet residents' needs. After investigation, all allegations were found to be unsubstantiated or unfounded.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident's personal rights were violated due to denial of in-person visitation despite a potential end-of-life condition.

The investigation found that the facility was following county and state public health guidelines accurately and allowed visitation based on the resident's medical documentation. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged violation of personal rights when a resident's family was not allowed in-person visitation despite the resident's potential end-of-life condition. The allegation was found unsubstantiated and the complaint was dismissed.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility issued an unlawful rate increase.

The investigation found that residents were notified of the rate increase more than 60 days prior to its effective date, with explanations for the increase due to operating expenses. Rate increases varied based on room market value and personal care needs. The allegation was unsubstantiated and no deficiencies were cited.

The complaint alleged that the facility issued an unlawful rate increase and that rate increases were not consistent for all residents. The allegation was found unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not properly trained, specifically regarding lifting and transferring residents.

The investigation found that staff training records were consistent with the facility's Program Plan and that staff received training upon onboarding. Annual transfer training was not conducted routinely but as needed. Staff interviews indicated knowledge of proper transfer techniques. The complaint allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff were not trained properly, resulting in improper lifting and transferring of residents. The allegation was unsubstantiated after review of training records, interviews, and additional complaint visit.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-02-19 regarding overcharging a resident and illegal eviction.

The investigation found that the resident required a higher level of care and that the facility issued a valid eviction notice due to non-payment, which was later resolved. The allegations of overcharging and illegal eviction were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that the facility was overcharging a resident and unlawfully evicting the resident. The investigation concluded these allegations were unsubstantiated.

The visit was conducted as a case management complaint investigation by phone due to COVID-19 precautions, to review concerns regarding medication administration by a private caregiver.

The investigation found that a resident's private caregiver was crushing medication for the resident, which is not allowed as the caregiver is not employed by the facility. This posed a potential health, safety, or personal rights risk to the resident.

The complaint was substantiated as the private caregiver was providing care and supervision, including medication assistance, which violates the Health and Safety Code.