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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 07/19/2023
Date Signed: 07/19/2023 05:14:39 PM

Document Has Been Signed on 07/19/2023 05:14 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:OBED D'AUTRUCHEFACILITY TYPE:
740
ADDRESS:1612 N MARTA DRIVETELEPHONE:
(925) 471-0671
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 4CENSUS: 3DATE:
07/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Obed D'Autruche, AdministratorTIME COMPLETED:
05:30 PM
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On 07/19/2023 Licensing Program Analysts (LPAs) L. Alexander and L. Hall conducted an unannounced Plan of Correction (POC). LPAs met Administrator, Obed D'Autruche and explained the purpose of the visit.

LPAs reviewed copies of Appraisal Needs and Services for all clients. LPAs reviewed copy of TB and health screening for S3 and S6.

LPAs extended POC due date from 07/11/23 to 07/24/23.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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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