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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 05/12/2022
Date Signed: 05/16/2022 09:18:15 AM

Document Has Been Signed on 05/16/2022 09:18 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
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:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Obed D'Autruche, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 05/12/2022 at 2:20 pm, Licensing Program Analyst (LPA) C. Fowler and arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Obed D'Autruche and explained the purpose of the visit.

Upon entry, LPA observed screening station that contained hand sanitizer and thermometer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA did not observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan and provided LPA with a copy via email.

The following deficiencies were observed during the visit:

-At 2:44pm, LPA observed a pair of scissors on the piano bench located in the living room.
-At 2:52pm, LPA observed a knife on top of the stove in the kitchen unlocked, knives are kept in unlocked drawer.
-At 2:53pm, LPA observed All laundry soap, Downy fabric softener, bleach, Pine clean, Lyson spray, Fauloso, Windex, WD-40, and Mr. Clean in a unlocked laundry room.
-At 2:59pm, LPA observed a rake, garden tools, bed rails, 2 ladders located in the back yard.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELISABETH CARE HOME
FACILITY NUMBER: 079200380
VISIT DATE: 05/12/2022
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Continued from LIC809

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Request updated documents

The following forms are to be updated and submitted to CCLD by 5/19/2022.

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610E Emergency Disaster Plan ARF LIC610D


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2022 09:18 AM - It Cannot Be Edited


Created By: Carol Fowler On 05/12/2022 at 04:00 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: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 by having laundry room unlocked with cleaning supplies listed above and garden tools bed rail and 2 ladders accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Administrator locked the laundry room door with the cleaning products and put garden tools, ladder, and bed rail in the locked garage. Deficiency cleared during visit.
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 by storing knives in an unlocked drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Administrator agreed to purchase a lock for the kitchen draw/cabinet and keep the knives locked. Administrator will email photo copies to CCLD no later then the POC date,
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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