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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 08/02/2023
Date Signed: 08/02/2023 10:34:34 PM

Document Has Been Signed on 08/02/2023 10:34 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: 4DATE:
08/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Obed D'Autruche, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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On 8/2/2023 at 1:40 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct Plan of Correction (POC) visit. LPAs met with Obed D'Autruche, Administrator, and explained the purpose of the visit.

LPA conducted a 1year Annual visit on 06/27/23 and cited facility.

Facility has the following deficiencies that were not cleared:

  • 87458(a), LPAs observed no Physicians Report
  • 87412(a), LPAs observed no completed staff records in files
  • HSC1569.695(c), LPAs observed no quarterly fire-drills completed
  • Civil Penalties for 87458(a) in the amount of $900.00 assessed immediately for the period of 7/25/2023 to 8/2/2023.
  • Civil Penalties for 87412(a) in the amount of $900.00 assessed immediately for the period of 7/25/2023 to 8/2/2023.
  • Civil Penalties for HSC 1569.695(c) in the amount of $900.00 assessed immediately for the period of 7/25/2023 to 8/2/2023.


LIC 809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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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: 08/02/2023
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LIC 809 Continued...


Civil Penalties in the total amount of $2700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. Appeal Rights, LIC421M, and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC809 (FAS) - (06/04)
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