312700693-2-12-2021-27-AS-TTRN-BY6RRQ-20210212121531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700693
Report Date: 02/12/2021
Date Signed: 02/12/2021 12:15:43 PM

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 LIVING		FACILITY NUMBER:	312700693
ADMINISTRATOR:	GILL, GURPREET		FACILITY TYPE:	740
ADDRESS:	4738 ROBIN CT		TELEPHONE:	(916) 251-7560
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	6	CENSUS: 5	DATE:	02/12/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Manjinder Gill		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/12/2021 LPA Tryon met with licensee Manjinder Gill to discuss an incident that took place in Septmeber 2020. The Department has investigated the incident. On 9/6/2020 in the afternoon resident R1 was sitting on the patio outside in the yard of the facility. Staff S1 was in the living room visually supervising R1 through the glass patio door and also supervising other residents in the house; and also assisting a resident to eat. Another staff was also present, but left the room for a few minutes to use the restroom, then assist another resident. At some point staff S1 became aware that resident R1 was no longer sitting in his spot on the patio. She did not know how long it had been since she saw him, but said she was looking back and forth from residents inside the house to resident R1 on the patio every 5 minutes. Staff S1 and staff S2 searched the faclity, and S2 took her car and searched the neighborhood. They were not able to locate R1. During this time they contacted licensees Gurpreet Gill and Manjinder Gill to notify them that R1 was missing. Police were notified by Manjinder Gill. Gurpreet Gill reviewed security camera files and saw R1 had left the facility at about 2:50 p.m. through the yard side gate. Gurpreet then drove through the neighborhood on her way to the facility looking for R1 but did not find him. At about 4:00 p.m. Gurpreet again went out to look for R1 and drove on the Sierra College campus. She found R1 laying on the ground partially on a walkway on the campus. She contacted the house to notify police who were there that she had found R1. Police responded. R1 was then pronounced dead at the scene. The staff and licensees said they were not aware that R1 was a risk for wandering away, and he had not previously attempted it. Therefore, no special supervision was provided to R1 However, in reviewing documentation gathered, including Physician's Report dated 7/28/2020 for an exam completed 6/4/2020, it was noted that the report had indicated that R1 was diagnosed with Mild Cognitive Impairment, was confused and disoriented, had wandering behavior, and was not able to leave the facility unassisted. The Department has concluded that the facility staff should have been aware of resident R1's mental.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 312700693
	VISIT DATE: 02/12/2021

NARRATIVE

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condition of confusion/disorientation and wandering behaviors based on his Physician Report; and adequate supervision interventions should have been in place to prevent R1 from leaving the facility unassisted.

The following deficiency is cited as per Title 22 Regulations and the California Health and Safety Code.
Appeal rights were provided and Exit Interview was conducted.

This meeting was held virtually due to concerns related to COVID-19. This document will be sent to the licensee by e-mail. LPA has asked that she print out 2 copies of the report, sign both copies, keep one copy of the report for the facility records; and send the other copy back to CCL for Licensing records. A hard copy of this report will be kept in the licensing paper Facility File to retain original licensee signatures.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 312700693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2021 Section Cited	1 2 3 4 5 6 7	87464(f) Basic Services. Basic services shall at a minimum include (1) Care and supervision as difined in Section 87101(c)(3) and H&S Section 1569.2(c). The requirement is not met as evidenced by: based on interview and review of records, it was learned that on 9/6/2020 resident R1 was sitting outside and was able tol leave the faciliy unsupervised.
	8 9 10 11 12 13 14	He was subsequently found about a mile away, emergency personnel responded and he was pronounced dead. Review of physician report dated 7/28/20 stated that R1 had Mild Cognitive Impoirment, was sonfused/disoriented, had a history of wandering and was not able to leave the facility unassisted.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
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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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC809 (FAS) - (06/04)

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