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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 09/19/2024
Date Signed: 09/19/2024 10:59:00 AM

Document Has Been Signed on 09/19/2024 10:59 AM - 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:
09/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Obed D'Autruche, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 09/19/2024, at 9:10 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Case Management - Proof of Correction (POC) visit. LPA met with Licensees/Administrator, Obed & Magdala D'Autruche and explained the purpose of the visit.

During the Non-Compliance Conference (NCC) meeting on 09/03/2024 the Licensees agreed to do the following in order to bring the facility in compliance.

Licensee to complete a total of 6 hours (2 hours minimum for each training course) of training that included: Reporting Requirements, Administrator Qualifications and Criminal Record Clearance. Trainings are to be provided by a Community Care Licensing approved vendor. Certificate of completion due 09/17/2024.



Administrator to send a copy of Admissions procedures for new residents
to the Department to be mailed by 09/17/2024.

The Licensee/Administrator requested an extension to the due date 09/17/2024 for 3 additional days in which LPA L. Alexander denied the request. The reason for additional days was not justifiable to show progress and effort in restoring compliance.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 079200380
VISIT DATE: 09/19/2024
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LIC809-C Continued...

Civil Penalties in the total amount of 2 days X $100.00 = $200.00 is assessed today for failure to meet POC date. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

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

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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