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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200380
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:16:15 PM

Document Has Been Signed on 06/18/2024 05:16 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:
06/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Magadala D'Autruche, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 06/18/2024, at 4:15 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Holmes arrived unannounced to conduct Proof of Correction (POC) visit. LPAs met with Licensee, Magadala D'Autruche and explained the purpose of the visit. Magadala phoned Administrator, Obed D'Autruche to inform. Obed arrived at the facility shortly after.

Administrator requested an extended due date from 06/05/24 to 06/12/24 in which LPA L. Alexander granted.

Facility has the following deficiencies that was not cleared:

  • 87616(b) = 6 days X $100 = $600.00

Civil Penalties in the total amount of $600.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.


SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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