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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801366
Report Date: 12/24/2024
Date Signed: 12/24/2024 09:47:05 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20241219130327
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: DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:David UballezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Executive Director David Uballez and reviewed records. Based on interviews conducted and records reviewed, medication technician, S1, gave resident, R1, medication from the package of R2. The medications were the same and to correct the error, S1 took the medication from R1's package and placed them into the already opened package of R2. S1 placed tape over the backing of the package to secure them. S1 was removed from medication duties for not following facility policies regarding administering medications. The correct medication was given and no medications were missing.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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