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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700693
Report Date: 09/09/2020
Date Signed: 09/10/2020 09:19:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 270
SACRAMENTO, CA 95833
FACILITY NAME:ROBIN COURT ASSISTED LIVINGFACILITY NUMBER:
312700693
ADMINISTRATOR:GILL, GURPREETFACILITY TYPE:
740
ADDRESS:4738 ROBIN CTTELEPHONE:
(916) 251-7560
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
09/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Gurpreet GillTIME COMPLETED:
05:00 PM
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On 9/9/2020 LPA Tryon spoke with Administrator Gurpreet Gill to follow up on an Incident and Death Report. Ms. Gill had called LPA shortly before to report the death of a male resident. On Sunday, 9/6/2020 the resident, R1 had gone out to sit on the patio in the back yard for a short time, as he has been doing regularly. Staff was inside the house, monitoring him through the window. Staff went to take another resident to the restroom. She returned a few minutes later at about 2:58 p.m., and noted that he was not in the chair on the patio. She searched and did not find him outside or in the house. 911 was contacted right away as well as R1's wife. Staff and police began to search the neighborhood for him. The police were searching neighbors' houses. At about 4:00 p.m. Administrator Gill drove onto the Sierra College campus, where she spotted R1's walker on the side of the main entrance road by the parking lot. She found R1 on the ground, immediately contacted the police who were searching closeby. Police and emergency responded, but R1 appeared deceased. Coroner responded and pronounced him dead on the spot.

LPA requested a copy of R1's LIC 602 Physician report, which Ms. Gill said she would e-mail right away. She said that R1 had never attempted to leave the facility before. She confirmed that R1 did not drive or have access to a car.

At this time, the matter will need further follow-up. Exit interview conducted. No deficiencies are cited at today's visit.

Due to concerns related to the COVID-19 pandemic, the meeting was held virtually by phone. LPA will forward this report to Administrator. She will be requested to print 2 copies, sign both, and return one copy to CCL for CCL records; and keep the other copy for the facility files. A hard copy of the signed report will be maintained in the facility file at CCL.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
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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