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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801366
Report Date: 10/09/2024
Date Signed: 10/09/2024 08:47:58 AM

Substantiated


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
09/09/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240909084057
FACILITY NAME:TIMBER RIDGE AT MCKINLEYVILLEFACILITY NUMBER:
126801366
ADMINISTRATOR:DAVID UBALLEZFACILITY TYPE:
740
ADDRESS:1400 NURSERY WAYTELEPHONE:
(707) 839-9100
CITY:MCKINLEYVILLESTATE: CAZIP CODE:
95519
CAPACITY:108CENSUS: 73DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:David UballezTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver the results of an investigation into the above allegation. LPA met with Executive Director David Uballez. Based on records reviewed and interviews conducted, LPA found evidence that shows staff gave resident more medication than was prescribed and made errors by removing more medication from the bubble packs than was needed then putting them back into the packs and attempting to seal with tape. Based on records reviewed, there were no misplaced or missing medication due to this however.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
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.
This report was reviewed with David Uballez and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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 2
Control Number 21-AS-20240909084057
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: TIMBER RIDGE AT MCKINLEYVILLE
FACILITY NUMBER: 126801366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed and
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Licensee shall ensure residents receive medication as ordered by the physician. Staff was removed from the medication technician position and received additional training. POC cleared at time of visit.
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interviews conducted, Licensee did not ensure resident received medications as ordered. This poses an Immediate Health risk to persons in care.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2