126801366-8-3-2023-21-AS-BMOS-CV7MTP-20230830095349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126801366
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:42:36 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
07/20/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230720135247

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:	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	David Uballez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff entered resident’s room and went through resident’s personal belongings

INVESTIGATION FINDINGS:

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At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to deliver the results of an investigation into the above allegation. LPA met with Executive Director David Uballez. Based on interviews conducted and a video recording of the incident, a staff member did search through a residents belongings while the responsible party was out of the room. Residents family inventoried the room and did not find anything missing. Facility conducted an internal investigation which resulted in the termination of the suspected staff. 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.

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: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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-20230720135247

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: 08/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2023 Section Cited HSC 1569.269(a)(2)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability:(2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance...This requirement is not	1 2 3 4 5 6 7	Licensee will request the Ombudsman to conduct resident rights training for all staff. Training to be scheduled by POC date of 08/04/2023. Signed attendance log will be submitted to CCL upon completion.
	8 9 10 11 12 13 14	met as evidenced by: Based on interviews and video recordings, Licensee did not ensure resident was granted privacy in their belongings. This poses an immediate personal rights 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: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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