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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 07/17/2024
Date Signed: 07/17/2024 06:58:28 PM

Document Has Been Signed on 07/17/2024 06:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELISABETH CARE HOMEFACILITY NUMBER:
079200380
ADMINISTRATOR/
DIRECTOR:		OBED D'AUTRUCHEFACILITY TYPE:
740
ADDRESS:1612 N MARTA DRIVETELEPHONE:
(925) 471-0671
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 4CENSUS: 2DATE:
07/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Obed D'Autruche, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
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On 07/17/2024 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management - Deficiency. LPA met with Obed D'Autruche, and explained the purpose of the visit.

LPA arrived to facility to conduct a complaint investigation (Control#15-AS-20240711093341) and during the visit LPA also discussed the deficiency not cleared. LPA discussed the deficiency and not receiving requested supported documents for foley catheter exception request which was cited on 05/29/2024. Administrator and Licensee gave several pages of documents in which LPA scanned with personal portable printer. LPA advised that documents will have to be reviewed. Licensee stated that they will send a revised exception request letter and a list of staff training to LPA via e-mail today.

Facility has the following deficiencies that was not cleared:

  • 87616(b) = 30 days X $100.00 = $3,000.00

Civil Penalties in the total amount of $3,000.00 is assessed today for failure to meet POC due date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights and LIC421FC provided.





SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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