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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126801366
Report Date: 12/19/2023
Date Signed: 12/19/2023 10:45:24 AM


Document Has Been Signed on 12/19/2023 10:45 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: 78DATE:
12/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Larona FarnumTIME COMPLETED:
11:00 AM
NARRATIVE
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit. LPA met with Larona Farnum, toured the facility, reviewed records and interviewed staff. This visit is due to a report of medication bubble packs being tampered with. On 11/28/2023, medication technician on duty observed a difference in the feel of a medication. Upon further investigation, 9 other residents medication cards were discovered to be tampered with. In all cards, the medication Oxycodone 5mg, was replaced with Quetiapine. The pills are very similar in appearance. The cards appeared to have been separated and then resealed to prevent detection. Licensee notified law enforcement immediately as well as CCLD and the Ombudsman. Licensee has implemented additional checks to ensure medication received by the pharmacy is intact and the cards are checked at every change of shift.
The incident is under investigation by the Humboldt County Sheriff's Department. LPA will follow up with facility upon completion of that investigation.

While touring the facility, LPA observed the medication cart near the entrance to the dining room and the medication technician was nowhere in sight. LPA observed the cart was unsecured and there was a plastic baggy on top that contained medication. There were approximately 16 residents present. LPA alerted the medication technician and the cart was secured immediately.

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 Larona Farnum and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 10:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the
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Licensee to provide refresher training for medication technicians on securing the medication cart.
Training to be scheduled by 12/20/2023, and completed by 01/19/2024. Self certification of
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centrally stored medication. This requirement is not met as evidenced by: Based on observation, medication cart was unsecured with no staff supervision. This poses an immediate risk to residents in care.
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completed training to be sent to CCL by 01/22/2024.

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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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