Atria Covell Gardens.

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.

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.

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.

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) 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 26 27 28 29 30 31 32 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) 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 26 27 28 29 30 31 32 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.

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.

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.

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.

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.

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.

...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.

Continued.... Allegation states that actions are because of Covid but no emergency health orders are in place. LPA conducted interviews, reviewed documents and found that at the current time, the facility is mitigating the spread of the Covid virus, as outlined in their Infection Control Plan. One way to cut down on the spread of the virus is to limit contact. A contact is considered 15 minutes exposure with a positive individual over the course of 24 hours. If residents are eating meals together, without masks, of course, there is a higher likelihood of someone unknowingly spreading the virus to others, as residents tend to socialize and linger over their meals together. The Department of Social Services advises Licensees to go by the strictest guidelines: the State Dept of Health, the CDC or the County Health Department. It was recommended by the Yolo County Health Department to close the communal dining areas to help mitigate the spread. This is within operating procedures, if warranted. As stated in CCR: 87555: General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. (b) The following food service requirements shall apply: (4) Meals on the premises shall be served in a designated dining area suitable for the purpose and residents encouraged to have meals with other residents. Tray service shall be provided in case of temporary need. 87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (E) The licensee shall ensure that staff encourage residents to follow infection control practices as necessary. Tray service is currently being provided to each resident. Orders are taken daily and a written record of food being delivered to each resident has been kept. Therefore LPA confirmed that food service is being provided to the residents as well as following the guidance of the Health Department. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a 1 year required inspection and met with Administrator Barbara Fleck on 8/3/2023 at approximately 9:00 AM. 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 records and then toured the facility with Administrator. Facility was found to be clean, orderly, and at a comfortable temperature of 74-76 F with all exits free from obstruction. 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 staff that do not handle medications. Facility has implemented an E-MAR program, utilizing bar codes and computer input for medication administration. Facility has an approved dementia plan of operation. There is an approved hospice waiver for nine (9) residents. Mitigation plan was approved by the Department on 07/02/21. An Infection Control Plan was submitted. There is an active Activities Program, with several engagements taking place each day. On the day of inspection there were Bridge and exercise classes, and a Tropical Themed Happy Hour taking place, with plenty of palm trees, leis, and tropical backdrops to set the mood. Continued... 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 26 27 28 29 30 31 32 Ten (10) rooms were inspected for water temperature and cleanliness and maintenance; all were within regulation. Fire clearance is approved for two-hundred and ten (210); one hundred forty-three (143) residents are currently in care at the facility during this inspection. The fire extinguishers were last inspected on 07/04/2023. The last Emergency Drill was on 07/31/2023 for the PM shift. The Fire Alarm Inspection took place on 05/24/2023. The Fire Sprinkler Inspection was on 05/25/2023. 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 navigate around tables and chairs. Plates of food looked attractive and had ample serving sizes. The dining room also offered options if the main course was not to their liking. No deficiencies during today's inspection. No citations issued. Exit interview conducted with the Administrator.