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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:43:52 PM

Document Has Been Signed on 04/28/2022 02:43 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:OBED D'AUTRUCHE, Administrator TIME COMPLETED:
03:15 PM
NARRATIVE
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On 4/28/2022, while at the facility for another reason, Licensing Program Analysts (LPAs) L. Ibo and K. Nguyen conducted an unannounced case management visit and met with Administrator OBED D'AUTRUCHE.

Administrator admitted that he did not submit incident report regarding bed bugs few months ago. LPAs explained the importance of completing the Incident Report for each occurrence regarding each resident and submitting the written LIC 624 to CCL within 7 seven days. Serious incidents will need to be reported within 24 hours to CCL, Ombudsman, Police and authorized representative as required.

LPAs conducted technical assistance with the following topics but not limited to; covid19 posters needs to be posted at the front door and common areas at the facility, covdi19 screening station with logs for all visitors, residents and staff and hand sanitizer should always be available at the front entrance.

Administrator stated they will comply with Title 22 regulations regarding reporting requirements.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC-9099 D. Failure to submit proof of correction (POC) by plan of correction due date or any repeat deficiencies within a 12-month period may result in civil penalties.

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

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 02:43 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/28/2022 at 12:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
05/02/2022
Section Cited
CCR
87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement was not met as evidence by:
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Licensee has agreed to review reporting requirements and submit self-certification to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident report regarding bed bugs at the facility which poses a potential health and safety risk to the residents in care.

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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: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


LIC809 (FAS) - (06/04)
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