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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 05/27/2026
Date Signed: 05/27/2026 07:09:12 PM

Document Has Been Signed on 05/27/2026 07:09 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: 6CENSUS: 2DATE:
05/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Obed D'Autruche, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On 05/27/2026 at 2:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator/Caregiver, Obed D'Autruche and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) residents. All may be non-ambulatory, one (1) bedridden, two (2) hospice. Administrator Certificate # 7008942740 expires 01/15/2028.

LPA toured facility with Mr.D'Autruche including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which four (4) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 100.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

LIC809-C Continued...
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/27/2026 07:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/27/2026 at 04:52 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: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by hot water temperature in all shared bathrooms including kitchen sink was not regulating at minmum 105 degrees F. Water temperature measured at 100.9 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
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Administrator will raise the water temperature on water heat and re-check. Send a photo of water temperature and submit a photo to CCLD by POC due date. While at facility Administrator adjusted the water heater and water measured at 108.7 Deficiency cleared during visit.

Repeat Violation. Assessed civil penalty $250.00 for today.
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having a lock on side exit gate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
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Administrator removed the lock during visit. Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


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: 05/27/2026
NARRATIVE
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Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 05/29/2025. Emergency Disaster Plan was last posted on 05/27/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/28/2026.

LPA reviewed two (2) residents records. LPA reviewed four (4) staff records and 4 of 4 have current first aid training and associated to the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 3:10pm lock on side gate
  • At 3:12pm gardening shovel/rake sitting up against backyard fence and black metal laying on ground up against the house
  • At 3:13pm a television sitting on ground outside by garbage cans


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/03/2026:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization - Reviewed
Updated LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance - Reviewed
Current Administrator’s Certificate - Reviewed

Exit interview conducted, a copy of this report provided, LIC421FC civil penalties along with Appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/27/2026 07:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/27/2026 at 05:46 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: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
§1569.695 Emergency Plans
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in by not conducting quarterly fire drills with staff for each staff including but not limited to all staff on different shifts which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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Administrator agrees to self-certify by reading and understanding the regulation moving forward and send self-certification to CCLD by POC due date. In addition, conduct fire drills with staff and have staff signatures as participating in the exercised drills.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by not having a tv monitor, gardening shovel, rake, other items located outside in backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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Administrator agrees to remove and clean the back yard, send a photo to CCLD by POC due date.

While at the facility Administrator removed the shovel, rake, umbrella pole and tv monitor to the garage. Deficiency cleared.

Repeat Violation. Assessed civil penalty $250.00 for today.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/27/2026 07:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/27/2026 at 06:39 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: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in S3 had expired First Aid expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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Administrator will send a copy of First Aid certificate for S3 to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
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