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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200380
Report Date:
05/29/2024
Date Signed:
05/29/2024 04:48:34 PM
Document Has Been Signed on
05/29/2024 04:48 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 HOME
FACILITY NUMBER:
079200380
ADMINISTRATOR/
DIRECTOR:
OBED D'AUTRUCHE
FACILITY TYPE:
740
ADDRESS:
1612 N MARTA DRIVE
TELEPHONE:
(925) 471-0671
CITY:
PLEASANT HILL
STATE:
CA
ZIP CODE:
94523
CAPACITY:
4
CENSUS:
3
DATE:
05/29/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:
Magadala D'Autruche, Licensee
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 05/29/2024 at 1:05 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Obed D'Autruche and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 4 (four) and hospice waiver for 2 (two). Administrator Certificate # 6030033740 expired 01/15/2024. Administrator stated that he submitted his renewal application which was dated 04/01/2024.
LPA toured facility with Obed including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 2 bedrooms are occupied by the residents and 3 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 77 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 113.5 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.
Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/08/2024. Emergency Disaster Plan was last posted on 05/29/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/28/2024.
LIC809-C Continued...
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
Document Has Been Signed on
05/29/2024 04:48 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
05/29/2024
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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having Administrator Certificate submitted before it expired and renewal documentation available not limited to CE which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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2
3
4
Administrator will submit all renewal certification documentation to CCLD by POC due date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a Physician's Report for R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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2
3
4
Administrator agree to submit R3's Physician's Report to CCLD by POC due 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:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
05/29/2024 04:48 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
05/29/2024
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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in by not having doctor's orders for bed rails for R1 and R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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Administrator agree to submit doctor's order for bed rails for R1 and R3 to CCLD by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
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 by not having documentation in R1's file for oxygen use sent to local fire dept. which poses a potential health and safety risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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3
4
Administrator agree to submit a copy of letter sent to local fire dept for R1's oxygen use.
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
05/29/2024 04:48 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
05/29/2024
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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having a No Smoking Oxygen in use signage which poses a potential health and safety risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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Administrator agree to submit a photo of signage on R1's door to CCLD by POC due date.
Type B
Section Cited
CCR
87211(a)(1)
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in by not notifying Licensing of R1's Hospitalizations and ER visits which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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Administrator agree to self-certify that they read the regulation and understand moving forward to comply with the regulations.
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
05/29/2024 04:48 PM
- It Cannot Be Edited
Citations on this Visit Report are Under Appeal!
Created By:
Lori Alexander-Washington
On
05/29/2024
at
04:24 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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
87616(b)
87616 Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a exception request for R1's Foley Catheter which poses a potential health and safety risk to persons in care.
POC Due Date:
06/05/2024
Plan of Correction
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3
4
Administrator agree to submit to CCLD an exception request for R1's Foley Catheter and provide all completed documentations by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
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:
05/29/2024
NARRATIVE
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LIC809-C Continued...
LPA reviewed 3 residents records. LPA reviewed 3 staff records and 3 of 3 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.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/05/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8