Atria Covell Gardens

Type of visit: Required - 1 Year

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Executive Director Ricky Ziese Dulay and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 9 residents. At approximately 9:30AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Fire sprinklers were throughout the building. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. LPA observed random rooms throughout the facility which had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required supply of perishable and non-perishable food. Emergency water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills monthly. At approximately 10:45AM, LPA reviewed 18 staff files. Staff files reviewed contained evidence of completed annual training and documented orientation training completed in the first four weeks of employment. First Aid/CPR certification was current. All employees requiring background checks are cleared. Continued on LIC809-C… At approximately 12:45PM, LPA reviewed 20 of 176 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. Medication records were organized and contained orders for each medication. Medications were secured and not accessible. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LPA received the following forms during this visit: Evidence of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.the state’s words, verbatim · CDSS document, Aug 24, 2026

Allegation investigated: Staff are not meeting resident's care needs

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA met with Administrator Rick Ziese-Dulay to discuss. During the course of the investigation LPA conducted a review of records and interviews along with observations. It was found that prior to admission not to exceed fourteen (14) days, a prospective resident is assessed. If the prospective resident is found to be a two (2) person assist, they are not admitted to the facility. In addition, once a resident is admitted and becomes a two (2) person assist, safety measures such as a request for a one on one to be provided along with physical and occupational therapy oversight is provided until resident can be discharged to receive the higher level of care needed. Continued on LIC9099C Unsubstantiated During LPA’s record review, there was no documentation of a resident admitted as a two (2) person assist. Based on interviews, record review and observations, the allegation Staff are not meeting resident’s care needs is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 21-AS-20260622121057

Type of visit: Office

The California Department of Social Services (CDSS) Community Care Licensing (CCL) Santa Rosa Regional Office conducted an in office, Legal Non-Compliance meeting today 07/08/2026 with Atria Covell Gardens, 577000881. Present in the meeting were: Regional Program Manager, Carla Nuti-Martinez, Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Jill Nakagawa, Administrator, Rick Ziese-Dulay, Assistant General Counsel - Operations, Jason Thomas, Regional Vice President, Natasha Georges and Outside Counsel, Joel Goldman. The purpose of this office meeting was to discuss areas of concern in the facility operations the as of result of a substantiated complaint received by the Department on 02/25/2026. On 06/10/2026 Licensee was cited for violating California Code of Regulation Title 22, Health and Safety Code (HSC) 1569.269 (a)(6). Parties present during the meeting agreed to a Non-compliance plan (NCC) plan for 2 years ending 07/07/2028 to ensure the facility is in compliance. Technical Support Provider (TSP) assistance was offered to Licensees during this meeting. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(f), or 1548(e) or (f), 1568.0822(f). No deficiencies citedthe state’s words, verbatim · CDSS document, Jul 8, 2026

Allegation investigated: Due to lack of staffing proper lifting practices were not being implemented, resulting in resident being injured.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to complete an investigation regarding the above allegation. LPA met with Administrator Rick Ziese-Dulay to review the findings of the investigation. The complaint alleges that “Due to lack of staffing proper lifting practices were not being implemented, resulting in resident being injured.” The complainant states that at the end of January 2026 resident R1 was not properly assisted, resulting in injury. The complainant stated that due to insufficient staffing, R1 was often assisted by only one (1) caregiver when R1 required two (2) or more staff for safe transfers. (Continued on 9099-C) Unsubstantiated (Continued from 9099) LPA reviewed assessments and R1’s physician’s report (dated 11/18/2024) which state R1 was a standby assist for bathing and dressing; and indicates that R1 was considered non-ambulatory and used a walker and wheelchair; able to independently transfer to and from bed. Internal care notes indicate that on 1/21/2026 R1’s responsible party was contacted to discuss R1 needing a higher level of care due to changes in cognition, not ambulatory status. Staffing records indicate that on 1/25/2026, the date of R1’s reported fall, there were two (2)med. techs and two (2)care staff scheduled for the AM and PM shifts. Incident Report submitted to the Department indicates that on 1/25/2026 R1 had an unwitnessed fall. Complainant states it was witnessed by a caregiver, who was helping R1 with their walker. Based on LPA’s record review and interviews, prior to R1’s fall of 1/25/2026, R1 was considered a standby assist to help with bathing and dressing/activities of daily living (ADLs), not ambulation. The complaint alleges that the facility did not dispense medication as prescribed. This allegation investigated under complaint #21 AS 20260204155138 and #21 AS 20260225125201. Based on a review of records, prior to the fall of 1/25/2026, R1 was a standby assist for certain ADLs and able to access and use their walker and wheelchair independently. Therefore, the allegation that “Due to lack of staffing proper lifting practices were not being implemented, resulting in resident being injured” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 21-AS-20260304160315

Allegation investigated: Staff did not provide medication assistance to resident in care resulting in hospitalization

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and to deliver findings. LPA met with Administrator Rick Ziese Dulay to discuss. The complaint alleges that Staff did not provide medication assistance to resident in care resulting in hospitalization. LPA reviewed Resident (R1) medication administration records (MAR), Service Plan, and Admission/Lease Agreement. Records indicate that R1physically moved in to the facility on 01/02/2026 and was to receive medication management services as listed on their service plan and assessment dated 12/31/2025. Continued on 9099-C... Substantiated Continued from 9099.... A review of R1’s MAR for January, 2026 shows no recorded medications or medications being administered. R1’s MAR for the month of February, 2026 shows the required medications but does not show that the administration of any medications was given to R1. R1 received multiple assessments from the time of move-in due to a change in condition, but staff failed to look at the administration of medications as agreed to in service agreement. A self-reported incident report by facility on 02/13/2026 states it was discovered on 02/09/2026 that R1 had not received medication since move-in on 01/02/2026. Medical records state that R1 suffered a hyperglycemic event and additional side effects, due to not receiving necessary insulin; which required hospitalization. Based on review of facility records, interviews with outside parties, and R1’s medical records the allegation that Staff did not provide medication assistance to resident in care resulting in hospitalization is Substantiated. Deficiencies cited. (See 9099-D). An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care based on Regulation HSC1569.269(a)(6). The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(f), or 1548(e) or (f), 1568.0822(f). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.the state’s words, verbatim · CDSS document, Jun 10, 2026 · control 21-AS-20260225125201

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jun 10, 2026

Health & Safety Code 1569.269(a)(6) Enumerated rights; severability To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: POC: The facility receives training from an outside source/regional office on resident care and coordination with accurate assessments and medication management. A plan for this training to be submitted to LPAby 6/12/2026, with training to be completed by 7/1/2026. Proof of completion to be submitted to LPA by 7/1/2026.

Allegation investigated: Staff did not take precautions to prevent the spread of illness

On 05/15/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete an investigation regarding the above allegation and deliver findings and met with the Maintenancee Director Arthur Morales, Maintenance Director/Administrator-of-the-Day, as Administrator Ricky Dulas was off site. The complaint alleges that Staff did not take precautions to prevent the spread of illness. The complainant states that the executive director waited until 72 hours had passed before following infection control guidelines when more than 50 residents had developed symptoms of a viral outbreak. LPA reviewed line list which was reported to County Department of Public Health (CDPH) and incident reports of the initial start of the outbreak. Continued on 9099-C Unsubstantiated Continued from 9099.... On 01/24/2026 two (2) residents sought medical care outside of the facility. On 01/25/2026 an additional resident sought medical treatment. At that point staff were made aware by residents and staff that there were three (3) cases of residents exhibiting the same symptoms and Administrator was notified. In less than 24 hours of the three (3) cases being identified, County Department of Public Health (CDPH) was contacted, families and residents were informed of the symptoms and Enhanced Infection Control protocols were immediately implemented. Reporting Party stated that there was a shortage of med techs. Although there were call-offs due to staff illness the Administrator and other trained staff assisted with those duties. Based on the documentation received from the Department of Public Health, the information reported to Community Care LIcensing (CCL), the notifications sent out to residents, families, visitors and staff, and the protocols put into place according to the facility’s Infection Control Plan the allegation that Staff did not take precautions to prevent the spread of illness is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence to substantiate the allegation therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 15, 2026 · control 21-AS-20260204155138

Allegation investigated: Staff did not remove expired food from refrigerator or freezer

On 04/17/2026, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation and met with the new Administrator Rick Dulay. The complaint alleges that “Staff did not remove expired food from refrigerator or freezer”. RP reported that resident (R1) has a lot of old food in refrigerator and freezer, some of it dating back months. LPA and Administrator inspected the apartment of R1 with their consent on 03/26/2026 and 04/17/2026. Continued on 9099-C.... Unsubstantiated Continued from 9099.... LPA found a number of boxes stacked around the apartment; but clean and no food remnants. The kitchen was clean and organized, with counters and sink free of old food or food trays/plates from past meals. There were multiple containers of food stored in the refrigerator and freezer but they were wrapped securely and dated. LPA did not observe anything that smelled bad nor see anything that appeared spoiled. On 03/26/2026 LPA asked R1 if they needed help with food storage and R1 stated they were independent and capable of managing their food; sometimes choosing to order room service rather than going to the dining room for meals. The Physician’s Report for R1 states they are independent. The Care Plan does not list any needs regarding meal service and R1 receives regular housekeeping and laundry services. Based on interview with R1, their personal rights and review of documents, the allegation that Staff did not remove expired food from the refrigerator and freezer is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview conducted with Administrator.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 21-AS-20260323111345

Allegation investigated: Staff do not ensure medications are dispensed as prescribed. Facility did not ensure adequate care and supervision.

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 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.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 21-AS-20260202132423

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 3, 2026

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: 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.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Feb 3, 2026

(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: 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.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: 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.

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

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 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) 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) 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.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 21-AS-20250422125218

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a 1 year required inspection and met with Executive Director Karrie Silvey. There is an approved hospice waiver for nine (9) residents. The facility has 141 residents in Assisted Living and Memory Care. LPA reviewed five resident files and four employee files and found them to be complete. All postings were up and visible as required. Toxins are stored in locked cabinets. There was a supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in the medication room and on the medication carts making them inaccessible to residents and only medication technicians are allowed to handle medications. Facility uses an E-MAR program for medication administration. The kitchen was clean, well-organized and well maintained. Food storage was as per regulation and there were adequate perishable and non-perishable food items as required in Title 22 regulation. Staff were practicing proper hygiene and food-handling. The dining room was clean, and set up with room for residents to practice social distancing or take meals in their apartments as cases of Covid have shown up in the community. Staff are working to mitigate the spread by practicing heightened infection control practices. The Activities Program keeps a very full calendar of events each day, including Yoga, Choir, Excursions, Bingo, Arts and Crafts. The fire extinguishers were last inspected on 07/03/2025. The last Emergency Fire Drill was on 07/12/2025 for the AM shift. The Fire Alarm Inspection took place on 04/29/2025. LPA discussed training documentation and the memory care unit. LPA requested proof of liability insurance, LIC500, staff and resident rosters. No citations issued. Exit interview conducted with Karrie Silvey, Executive Director.the state’s words, verbatim · CDSS document, Jul 29, 2025

Allegation investigated: Facility did not issue a refund to a resident in care. Facility charged resident for services not rendered

On 7/9/2025, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue an investigation and deliver findings regarding the above allegations. LPA met with Karrie Silvey, Executive Director, to discuss the findings. The complaint alleges that Facility did not issue a refund to a resident in care. Resident R1 was out of the facility for two nights in hospital but was charged by the facility for receiving care. LPA reviewed the lease agreement signed by R1 which specifies that there are no refunds regarding care costs when a resident is away from the facility, including hospital stays, vacations, etc. Therefore, the allegation that the Facility did not issue a refund to a resident in care is Unsubstantiated. Continued on 9099-C Unsubstantiated Continued from 9099... In addition, the complaint alleges Facility charged resident for services not rendered. The complaint states R1 was charged for one month, including care costs, although R1 moved out of the facility because the facility could not meet R1’s care needs due to medical condition. LPA reviewed the Admissions Agreement signed by R1 which states that a 30-day notice must be given when a resident chooses to terminate their lease agreement. A 30-day notice was not received by the facility from R1 until May 6, so costs incurred through June 4 would be the responsibility of R1 as specified under the lease agreement. Additionally, the complaint states that R1’s needs could not be met: requiring 24 hour care, and therefore, requiring care at another facility. LPA questioned staff S1 if 24-hour staff was available to meet the needs of R1. S1 stated the facility was not contacted by R1 notifying facility of change in condition or if facility was able to meet R1’s care needs. According to S1 facility does have 24-hour staffing able to meet the needs of R1, so the 30-day notice to terminate the lease agreement was still required. Therefore, the allegation that Facility charged resident for services not rendered is Unsubstantiated. Although the allegations may have happened there is not a preponderance of evidence to substantiate the allegations therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 21-AS-20250512101522

Allegation investigated: Staff did not ensure a resident's room is properly operating

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to initiate a complaint investigation regarding the above allegation and delivered findings. LPA met with Karrie Silvey, Executive Director, to discuss. LPA made an inspection of the resident's (R1) room and found the air conditioning unit to be inoperable. R1 stated that they had reported the broken unit to facility multiple times but unit had not yet been repaired. Front desk received a call from R1 on 6/9/25, and a work order was filed. Facility did provide R1 a portable unit to use as a temporary measure until repairs can be made. LPA reviewed maintenance and staff records and found that facility was in the process of making repairs. A private repair company did inspect the unit on 06/09/2025. Parts were submitted for approval, ordered and upon receipt a repair date was scheduled for 07/10/2025. Based on review of documentation the allegation that Staff did not ensure a resident's room is properly operating is unsubstantiated. Although the allegation may have happened there is not a preponderance of evidence to substantiate the allegation therefore the allegation is unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2025 · control 21-AS-20250701115424

Type of visit: Case Management - Incident

On 07/09/2025, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to meet with Karrie Silvey (KS), Executive Director, regarding a Case Management- Incident Report. The inspection is being conducted to review incident report of 06/08/2025 where resident (R1) took a pill found on the floor of their apartment. R1 reported their actions to staff. As the pill could not safely be identified EMTs were called and R1 was transported to hospital for observation. R1 was evaluated and returned to facility same day. LPA conducted an incident report review of the resident medication error with KS. KS reported that the facility has conducted re-training with medication technicians with the Six Rights of the Medication Administration to ensure medications are administered correctly. Per conferencing with administration the licensee will ensure that clients are administered medication properly. (See 809-D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Jul 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jul 9, 2025

87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on LPA's review of self-reported incident report where resident (R1) self-administered a pill off their floor, but unable to identify which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: Administrator agrees to ensure med. techs receive additional medication training before passing meds. Training for med. techs. occurred 06/16/2025. Proof of training received during today's inspection. POC cleared.

Allegation investigated: Licensee does not ensure that resident's room is kept in a clean condition. Licensee does not ensure that facility is not odiferous.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 05/01/2025 to continue the investigation and deliver findings regarding the above allegations. LPA met with Administrator Carol Dowell. The complaint alleges that Licensee does not ensure that resident’s room is kept in a clean condition and that Licensee does not ensure that facility is not odiferous. It is alleged that R1’s carpeting was saturated with blood and urine and that the room smelled of urine. LPA conducted an inspection of nine (9) resident rooms and found that two (2) of the nine (9) rooms were malodorous and had stains on the carpeting. Continued on 9099-C Substantiated Continued from 9099... Based on LPA’s observations, the preponderance of evidence standard has been met, therefore the allegations that Licensee does not ensure that resident’s room is kept in a clean condition and Licensee does not ensure that facility is not odiferous are SUBSTANTIATED. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Assistant Administrator.the state’s words, verbatim · CDSS document, May 1, 2025 · control 21-AS-20250421135045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303 · Plan of correction due date: May 1, 2025

87303 Maintenance and Operations:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA’s observation of stains in carpet and strong urine smell which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Licensee agrees to clean carpeting and provide pictures of the cleaning/repair or replacement of the carpeting in affected rooms.

Type of visit: Case Management - Incident

LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit regarding multiple incidents around R1. LPA met with Administrator via phone. The Administrator and staff are monitoring R1 for any changes in condition and seeking supports for his care. LPA conducted interview and collected documents. There were no deficiencies and no citations issued at the time of visit. Manager on Duty, Andrew Conley reviewed and signed the report, for Administrator Barbara Fleck who was not on site at the time of visit.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Inspection. LPA met with Barbara Fleck, who accompanied LPA on a tour of the facility. The facility was found to be a comfortable temperature and was clean and well maintained. The dining room was decorated with small vases on the tables, which were arranged well, so that walkers and wheelchair access was unencumbered. The kitchen was immaculately clean and well organized. There was an ample supply of perishable and nonperishable foods as required per Title 22. Foods prepared for the upcoming meal were under refrigeration and covered. Safe food handling procedures were being followed. Cleaning solutions and toxins were locked in a closet separate from food storage. The maintenance director provided LPA with a complete record of water temperature logs, and the latest fire inspection. The facility and grounds were well maintained and walkways were clear of obstructions. Grounds were free of debris. LPA and Administrator toured the memory care unit and found residents to be clean and appropriately dressed. There is an established activity program and many residents were participating at the time of inspection. Apartments in memory care were clean, organized and free of hazards. There are apartments for Assisted Living on the first, second and third floors which can be accessed by elevator and stairs. There is a movie theater on the first floor and a library and gym on the second floor as well as rooms housing computers with internet access. There are also laundry rooms for residents to use. LPA found staff and residents had only positive things to say about the facility. There were no deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Jul 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a 1 year required inspection and met with Administrator Barbara Fleck LPA met with Administrator, Barbara Fleck and the Resident Services Director, Susan Alexander on 07/16/2024 at approximately 1:40 PM. Facility has an approved dementia plan of operation. There is an approved hospice waiver for nine (9) residents. The facility has 156 residents in Assisted Living and Memory Care. All visitors are required to register at the front desk upon entry and residents are supposed to sign out at the front desk when leaving the facility. LPA reviewed five resident files and five employee files and found them to be complete, including updated Needs and Services Plans. All postings were up and visible as required. Toxins are stored in locked cabinets. There was a supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in the medication room and on the medication carts making them inaccessible to residents and only medication technicians are allowed to handle medications. Facility uses an E-MAR program, utilizing bar codes and computer input for medication administration. There is an active Activities Program, with several engagements taking place each day. LPA will continue Annual Inspection of facility at a later date. No deficiencies were found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Jul 16, 2024

Allegation investigated: Staff are not providing adequate care and supervision to the residents Facility is not clean and sanitary

Licensing Program Analyst (LPA) Nakagawa arrived unannounced at Atria Covell Gardens on 2/1/24 at approximately 9:15 AM to conduct an investigation regarding the above allegations. LPA met with Administrator Barbara Fleck who allowed access to the facility and provided LPA with an immediate tour. LPA made a tour of the facility, including the dining room, common areas and the Memory Care unit. Continued on 9099-C Unsubstantiated It is alleged Staff are not providing adequate care and supervision to the residents. The reporting party states that residents in Memory Care are locked in their rooms due to a Covid outbreak. LPA toured the facility, focusing on the Memory Care unit. LPA made observations, reviewed documents and conducted interviews. It was reported to LPA that residents in Memory Care were asked to isolate in their rooms due to cases of Covid on the unit, under the direction of Public Health. Residents are not locked in their rooms as they are not locked from the inside. They are currently locked form the outside to assist in keeping residents separated from other residents who may be infectious. The reporting party stated that residents are not being cared for, checked on, helped to the bathroom, or given water. LPA found residents to be clean, groomed and dressed appropriately. At the time of inspection ,it appeared that residents had recently been served breakfast, which included a selection of beverages (water, juices). There were 7 staff at the time of inspection, who were all engaged in duties of care, housekeeping and activities. It was reported to L PA that Lunch and Dinner are also served, with beverages. There are also 3 snacks/hydration breaks throughout the day. Additionally, residents are checked regularly for hygiene and hydration and there are call buttons in the bathrooms. It is also alleged that Facility is not clean and sanitary. The reporting party stated that they are living in filthy conditions. At the time of inspection the facility was found to be clean, comfortable and well-maintained. Bathrooms were clean and sanitary. Sinks, toilets and showers were clean, and wastebaskets were empty and lined. Bedrooms were neat and tidy. Most beds were made, except for several rooms where residents were resting. Common areas in Memory Care were clean, including dining room; kitchen and serving area were also clean and sanitary. Although the allegations may be true, based on observations, statements and documents, there is not a preponderance of evidence to prove the allegations true or false therefore the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 21-AS-20240131120921

Allegation investigated: Staff are not ensuring resident's medication is being administered as prescribed.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on December 15, 2023 at approximately 12:05 PM to continue a complaint investigation and deliver findings regarding the above allegation. The allegation states that Staff are not ensuring resident's medication is being administered as prescribed. Continued on 9099-C... Unsubstantiated ...Continued from 9099 This investigation has included site visits, interviews and document reviews. The following determinations were made: according to the medication log R1 received medications as prescribed. The complainant reported R1 went to the front desk to report symptoms and questions about medications. Complainant states that they contacted R1's family and staff. . LPA was unable to corroborate complainant's statements with R1's family or staff. Reports from physician state that the medications in question would not have caused the symptoms R1 had Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegations true or false therefore the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 15, 2023 · control 21-AS-20231030091516