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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126801366
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:54:05 AM


Document Has Been Signed on 10/31/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MCKINLEYVILLEFACILITY NUMBER:
126801366
ADMINISTRATOR:DAVID UBALLEZFACILITY TYPE:
740
ADDRESS:1400 NURSERY WAYTELEPHONE:
(707) 839-9100
CITY:MCKINLEYVILLESTATE: CAZIP CODE:
95519
CAPACITY:108CENSUS: 81DATE:
10/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:David UballezTIME COMPLETED:
12:10 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to two unexpected deaths that occurred at the facility. LPA met with Administrator David Uballez and reviewed records.
Resident, R1, was seen at the hospital on 09/13/2023 for Pneumonia. Discharge paperwork requested R1 to see a cardiologist as soon as possible. R1 was also referred to Home Health. R1 continued to decline and a hospice consult was requested. Facility updated care plan and was conducting safety checks every 2 hours. On 10/26/2023, care staff found R1 unresponsive and emergency personnel were contacted. All notifications were made by facility.

On 10/19/2023, Resident, R2, was vomiting and experiencing shortness of breath. Facility contacted emergency personnel and R2 was transported to the hospital and admitted. Facility was notified by responsible party on 10/22/2023, that R2 had passed. Facility requested a copy of the death certificate.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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