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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200380
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:23:33 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220224160544
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: 1DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Obed D'Autruche, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee failed to issue proper refund
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/2/2022 starting at 10:55 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a complaint investigation for the above allegation. LPA met with Registered Nurse, Magdala D'Autruche and explained the purpose of the visit. Administrator, Obed D'Autruche later arrived at 11:20 AM.

During the complaint investigation, LPA toured facility, reviewed records and interviewed staff. It is alleged Licensee failed to issue proper refund. Based on record review, resident (R1) was admitted to the facility on 2/14/22 and R1 passed away at the hospital on 2/21/2022. R1's belongings were removed from facility on 2/27/2022, therefore, facility is still within the 15 day period to issue a refund to R1's responsible party.

This agency has investigated the complaint alleging Licensee failed to issue proper refund. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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