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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200380
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:42:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220421131342
FACILITY NAME:ELISABETH CARE HOMEFACILITY NUMBER:
079200380
ADMINISTRATOR:OBED D'AUTRUCHEFACILITY TYPE:
740
ADDRESS:1612 N MARTA DRIVETELEPHONE:
(925) 471-0671
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:4CENSUS: 2DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:OBED D'AUTRUCHETIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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On 4/28/2022 , Licensing Program Analysts (LPA) L. Ibo and K. Nguyen arrived at the facility unannounced to investigate the above allegation. LPAs met with Administrator OBED D'AUTRUCHE and informed the purpose of the visit.

LPAs conducted interview, Administrator admitted that facility had bed bugs on of the resident’s room #2, the incident happened couple of months ago, Administrator stated it was sometime in June 2021. Facility hired professional exterminator (heatRx) on June 4, 2021 to eliminate beg bugs. This incident was not reported to CCLD office. Facility was observed to be clean.

...Continue LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 3
Control Number 15-AS-20220421131342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELISABETH CARE HOME
FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
87303(a)
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87303 (a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Deficiency is corrected on July 2021.
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Based on interview and inspection, the Administrator failed to ensure the facility is free of pest which poses potential health and safety risks to residents in care. Administrator admitted that there were bed bugs at the facility couple of months ago.
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Facility hired exterminator to irradiate bed bugs from room #2.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220421131342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELISABETH CARE HOME
FACILITY NUMBER: 079200380
VISIT DATE: 04/28/2022
NARRATIVE
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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with OBED D'AUTRUCHE.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3