126801366-5-17-2021-21-AS-BMOS-C35R8B-20210518124739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126801366
Report Date: 04/16/2021
Date Signed: 05/17/2021 09:53:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210225144828

FACILITY NAME:	TIMBER RIDGE AT MCKINLEYVILLE		FACILITY NUMBER:	126801366
ADMINISTRATOR:	UBALLEZ, DAVID		FACILITY TYPE:	740
ADDRESS:	1400 NURSERY WAY		TELEPHONE:	(707) 839-9100
CITY:	MCKINLEYVILLE	STATE: CA	ZIP CODE:	95519
CAPACITY:	108	CENSUS: 75	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Larona Farnum		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's personal property

Facility staff did not prevent residents from engaging in a physical altercation

INVESTIGATION FINDINGS:

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***Report was amended virtually*** At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold met with Executive Director Larona Farnum, unannounced, at the Eureka facility to deliver findings to the above allegation. Based on interviews conducted and a review of records, facility followed regulation and their plan of operation as it pertains to resident property. The facility is not able to monitor what a resident does with their personal property at all times. Resident was admitted to facility directly from the hospital. There was no mention of cash going missing at the time of admission. Due to the incident occuring in 2019, staff were not able to recall clearly the events of that time. There were no incident reports filed regarding missing cash during that timeframe. Facility notified responsible party when it was observed an item was missing at a later date. When the item was found at a later time, the facility notified responsible party the item was found.
Continued on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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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Control Number 21-AS-20210225144828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TIMBER RIDGE AT MCKINLEYVILLE	FACILITY NUMBER: 126801366
	VISIT DATE: 04/16/2021

NARRATIVE

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Based on interviews conducted and a review of records, facility followed regulation to prevent residents from assaulting other residents. Care plans are created and reviewed with staff for each resident. There were no indications in the records that a certain resident was assaultive. When facility staff observe residents in an unsafe situation, they redirect as trained and follow reporting requirements.

Based on interviews conducted and a review of documents the allegations are Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No citations issued.

Original signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

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