126801366-8-20-2024-21-AS-VBEI-DA3NW4-20241015104856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126801366
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:18:21 PM

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
06/25/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240625115209

FACILITY NAME:	TIMBER RIDGE AT MCKINLEYVILLE		FACILITY NUMBER:	126801366
ADMINISTRATOR:	DAVID UBALLEZ		FACILITY TYPE:	740
ADDRESS:	1400 NURSERY WAY		TELEPHONE:	(707) 839-9100
CITY:	MCKINLEYVILLE	STATE: CA	ZIP CODE:	95519
CAPACITY:	108	CENSUS: 80	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	David Uballez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility failed to meet resident's care needs

INVESTIGATION FINDINGS:

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At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director David Uballez and reviewed records. Based on records reviewed and interviews conducted, LPA observed Residents, R1, care plan noted a history of skin breakdown and was prone to skin tears on hands and arms. The care plan directs caregivers to monitor skin condition regularly. LPA reviewed staff communication logs and found notes regarding when R1 falls or complains of pain. There was no documenation following up on injuries sustained from the falls or the care provided. On 06/17/2024, records show R1 was found on the hallway floor. Staff observed a skin tear. LPA did not locate any additional documenation regarding the care or condition of the injury. LPA did not locate any documenation that the physician was notified. Continued on LIC9099-C...

Substantiated

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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 4

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
06/25/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240625115209

FACILITY NAME:	TIMBER RIDGE AT MCKINLEYVILLE		FACILITY NUMBER:	126801366
ADMINISTRATOR:	DAVID UBALLEZ		FACILITY TYPE:	740
ADDRESS:	1400 NURSERY WAY		TELEPHONE:	(707) 839-9100
CITY:	MCKINLEYVILLE	STATE: CA	ZIP CODE:	95519
CAPACITY:	108	CENSUS: 80	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	David Uballez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility failed to seek timely medical attention

INVESTIGATION FINDINGS:

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At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director David Uballez and reviewed records. Based on records reviewed and interviews conducted, on 06/17/2024, Resident, R1, suffered a fall resulting in a skin tear on their arm. Emergency personnel were not needed for a minor injury and R1 did not express any further discomfort. On 06/22/2024, staff observed R1's injury to be red and swollen and contacted emergency personnel immediately.

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:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20240625115209

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: 08/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/21/2024 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care:(a)(2)The licensee shall provide assistance in meeting necessary medical and dental needs.This requirement is not met as evidenced by: Based on records reviewed,	1 2 3 4 5 6 7	Administrator conducted a meeting with all care staff regarding observing and reporting residents conditions. POC cleared during visit.
	8 9 10 11 12 13 14	Licensee did not ensure residents medical needs were met. This poses an immediate Health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20240625115209

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
	VISIT DATE: 08/20/2024

NARRATIVE

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On 06/22/2024, staff observed R1's skin tear to be red and swollen and contacted emergency personnel immediately. R1 was admitted to the hospital.
LPA discussed with Administrator the need to document the care provided to residents to ensure their medical needs are met.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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