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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 06:54:17 PM

Document Has Been Signed on 07/17/2024 06:54 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:
11:30 AM
MET WITH: Obed D'Autruche, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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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.

When LPA arrived to facility to conduct a complaint investigation (Control#15-AS-20240711093341). Upon entry into the facility, LPA was greeted by an individual and observed 2 (two) individuals sitting down on the couch in the living room area, 1 (one) individual standing in the kitchen area. LPA observed 1 (one) resident sitting at the dining room table, and 2 (two) other family members not including the Licensee and Administrator, Obed & Magdala D'Autruche.

LPA had a conversation with Magdala regarding the observed individuals. Magdala stated that her family was visiting from Haiti and that they were not living at the facility but "Visiting."

LPA spoke with Obed regarding their family guests. Obed stated that their family relatives have been "visiting" for about 2 weeks and that they are planning to receive work permits within the next 2 weeks.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in continuing civil penalties.

Immediate Civil Penalty Assessed today for $3,000.00

Exit interview conducted. A copy of this report, appeal rights provided and LIC421BG was given to Licensee/Administrator.
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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Document Has Been Signed on 07/17/2024 06:54 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/17/2024 at 12:35 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: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2024
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review...Health and Safety Code Section 1569.17(b) shall prior to working, residing in a licensed facility:
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Administrator will have all uncleared individuals removed from the house by POC due date.
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Based on observation and interview the licensee did not comply with the section cited above in by not having fingerprint clearance for 6 (six) family relatives that are residing at the facility submitted to CCLD which poses a potential health, safety or personal rights risk to persons in care.

Immediate Civil Penalty Assessed of $3,000.00
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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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
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