Elisabeth Care Home
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
1612 N Marta Drive · Pleasant Hill, 94523
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity1thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency8thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Elisabeth Care Home scores D. Better than 36% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: bottom 1%. Repeats: top 0%. Frequency: bottom 8%.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
52
Last citation
May 25
Finding distribution
64 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Jun 202322 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
What must this facility report to the state — and how fast?Cited May 202422 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 079200380
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Samuel D'autruche Inc.
Inspections & citations
17
reports on file
69
total deficiencies
8
Type A (actual harm)
5
dementia-care citations
InspectionJune 13, 2025No deficiencies
Plain-language summary
On June 13, 2025, inspectors conducted a follow-up visit to verify corrections from an earlier inspection and found that while some issues had been fixed, three deficiencies remained uncorrected past the deadline. The facility was assessed $600 in civil penalties for the failure to correct these issues on time and will face additional daily penalties until they are resolved. An exit interview was held with the administrator.
View full inspector notes
On 06/13/2025 at 2:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Proof of Correction (POC) visit and met with Licensee/Administrator, Obed D’Autruche. LPA explained the purpose of the visit to Licensee. On 05/28/2025, LPA L. Alexander conducted an Annual Inspection in which deficiencies were cited. The POC due date was 06/11/2025. Facility has the following deficiencies that was cleared : CCR 87465(d) CCR 87303(e)(2) Facility has the following deficiencies that was not cleared : 3. CCR 87412(a) $100.00 x’s 2 days = $200.00 4. HSC 1569.625(b)(2) $100.00 x’s 2 days = $200.00 5. CCR 87465(e) $100.00 x’s 2 days = $200.00 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 and LIC421FC provided.
Other visitMay 28, 2025Type B7 deficiencies
Plain-language summary
During an unannounced annual inspection on May 28, 2025, inspectors found the facility met most safety and care standards, but noted several maintenance issues: wooden materials and debris stored in the backyard, a bed with bedding in the garage, uncleaned flooring in rear bathrooms, and broken flooring in the rear bathroom. The facility was also asked to submit updated paperwork including insurance documentation and emergency plans by early June 2025.
View full inspector notes
On 05/28/2025 at 3:10 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator, Obed D'Autruche and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) non-ambulatory and where one (1) bedridden resident can reside in Bedroom #1. Hospice waiver approved for two (2) residents. Administrator certificate #7008942740 expires 01/15/2026. LPA toured facility with Obed including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by one (1) resident and two (2) bedrooms are occupied by live-in staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 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 126, 128 and 128.7 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. Sharps were locked and inaccessible to residents. LIC809-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809-C Continued... 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 05/28/2025. Emergency disaster drill was last conducted on 03/15/2025. LPA reviewed one (1) resident's records. LPA reviewed three (3) staff records and three (3) of four (4) have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed wooden coat rack, piece of wood lumbar, and other materials along the outside fence and back yard LPA observed a bed with sheets/blanket/pillows located in the garage LPA observed the flooring in rear bathrooms and shower were not clean LPA observed piece of wood flooring broken at rear bathroom Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/04/2025: Updated LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Certificate of Liability Insurance 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. Exit interview conducted. Appeal Rights and a copy of this report provided.
Regulation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having backyard cleaned up, flooring repaired in rear bedroom which poses a potential health and safety or risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator agreed to clean yard, remove items from back yards, and repair the broken wood in rear bedrooms by sending a photo to CCLD by POC due date.
Regulation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by not having the floor surfaces clean including but not limited to bathroom and shower floors in rear bedrooms which poses a potential health and safety risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator agreed to clean all flooring including rear bedrooms and bathrooms by sending a photo to CCLD by POC due date.
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by not having the water temp. measuring between 105-120 degree F. The water temperatures measured 126, 128.7 and 128 degree F in rear bathroom which poses a potential health and safety risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator will adjust water temp. and send a photo to CCLD by pOC due date.
Regulation
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Inspector finding
Based on interview and record review, the licensee did not comply with the section cited above in by not having on file including but not limited to application, First Aid/CPR, and employee documents for S4 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator agreed to submit S4 documents to CCLD by POC due date.
Regulation
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivisi…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having annual trainings for S1, S2 and S3 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator agreed to complete staff trainings and submit training certificates to CCLD by POC due date.
Regulation
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a physician's report for R1 that indicates that R1 can administer their own prescription and non-prescription medications which poses a potential health and safety risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator to submit an updated Physician's Report for R1 to CCLD by POC due date.
Regulation
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following informa…
Inspector finding
Based on observation and record review, the licensee did not comply with the section cited above in by having R1's doctor's orders on file for prescription and non-prescription medications including but not limited to vitamins and herbal supplements which pose a potential health and safety risk to persons in care. POC Due Date: 06/11/2025 Plan of Correction 1 2 3 4 Administrator agreed to submit a copy of doctor's orders for all prescription and non prescription medications for R1 to CCLD by P…
Other visitSeptember 19, 2024No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
This was a follow-up visit on September 19, 2024, to verify that the facility had completed corrections ordered after a prior compliance meeting on September 3, 2024. The facility failed to submit required staff training certificates and admission procedures by the September 17 deadline, and the administrator's request for a three-day extension was denied; the state assessed a $200 penalty for this non-compliance and warned that daily penalties would continue until the deficiencies were corrected.
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On 09/19/2024, at 9:10 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Case Management - Proof of Correction (POC) visit. LPA met with Licensees/Administrator, Obed & Magdala D'Autruche and explained the purpose of the visit. During the Non-Compliance Conference (NCC) meeting on 09/03/2024 the Licensees agreed to do the following in order to bring the facility in compliance. Licensee to complete a total of 6 hours (2 hours minimum for each training course) of training that included: Reporting Requirements, Administrator Qualifications and Criminal Record Clearance. Trainings are to be provided by a Community Care Licensing approved vendor. Certificate of completion due 09/17/2024. Administrator to send a copy of Admissions procedures for new residents to the Department to be mailed by 09/17/2024. The Licensee/Administrator requested an extension to the due date 09/17/2024 for 3 additional days in which LPA L. Alexander denied the request. The reason for additional days was not justifiable to show progress and effort in restoring compliance. LIC809-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809-C Continued... Civil Penalties in the total amount of 2 days X $100.00 = $200.00 is assessed today for failure to meet POC date. 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.
Other visitJuly 26, 2024No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
This was a follow-up visit on July 26, 2024, to verify that a previous violation had been corrected. The facility had been cited a week earlier for having unauthorized residents living there, and inspectors confirmed that those individuals had been removed and the problem was resolved. No new violations were found during this visit.
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On 07/26/2024, at 9:00 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Holmes arrived unannounced to conduct Proof of Correction (POC) visit. LPAs met with Licensees/Administrator, Obed & Magadala D'Autruche and explained the purpose of the visit. LPAs toured the entire facility including all bedrooms, bathrooms and garage. Licensees were cited and assessed immediate civil penalties on 07/17/2024 for CCR 87355(e). LPAs did not observe any additional individuals at the facility that weren't associated in Guardian. Magadala e-mailed LPA on 07/18/2024 to advise that her family relatives were removed from the facility and are no longer residing at the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitJuly 17, 2024No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
On July 17, 2024, inspectors visited the facility to follow up on a previous complaint and to check on an uncorrected deficiency related to a request for a foley catheter exception that had been cited in May 2024. The facility had not provided the required supporting documents for this exception request within the required timeframe, and was assessed $3,000 in civil penalties; the facility will face additional daily penalties until this deficiency is corrected. The administrator provided documents during the visit and committed to sending a revised exception request letter and staff training records to the licensing program.
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On 07/17/2024 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management - Deficiency. LPA met with Obed D'Autruche , and explained the purpose of the visit. LPA arrived to facility to conduct a complaint investigation (Control#15-AS-20240711093341) and during the visit LPA also discussed the deficiency not cleared. LPA discussed the deficiency and not receiving requested supported documents for foley catheter exception request which was cited on 05/29/2024. Administrator and Licensee gave several pages of documents in which LPA scanned with personal portable printer. LPA advised that documents will have to be reviewed. Licensee stated that they will send a revised exception request letter and a list of staff training to LPA via e-mail today. Facility has the following deficiencies that was not cleared : 87616(b) = 30 days X $100.00 = $3,000.00 Civil Penalties in the total amount of $3,000.00 is assessed today for failure to meet POC due 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 and LIC421FC provided.
Other visitJuly 17, 2024Type A1 deficiency
Inspector: Lori Alexander-Washington
Plain-language summary
On July 17, 2024, a licensing analyst conducted a complaint investigation at the facility and found deficiencies related to case management practices, which resulted in a $3,000 civil penalty. The analyst also observed family members from Haiti visiting the facility, whom the operators stated had been there for about two weeks and were in the process of obtaining work permits. The facility was cited for violations of California regulations and given the opportunity to correct the deficiencies.
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On 07/17/2024 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management - Deficiency. LPA met with Obed D'Autruche , and explained the purpose of the visit. When LPA arrived to facility to conduct a complaint investigation (Control#15-AS-20240711093341 ). Upon entry into the facility, LPA was greeted by an individual and observed 2 (two) individuals sitting down on the couch in the living room area, 1 (one) individual standing in the kitchen area. LPA observed 1 (one) resident sitting at the dining room table, and 2 (two) other family members not including the Licensee and Administrator, Obed & Magdala D'Autruche. LPA had a conversation with Magdala regarding the observed individuals. Magdala stated that her family was visiting from Haiti and that they were not living at the facility but "Visiting." LPA spoke with Obed regarding their family guests. Obed stated that their family relatives have been "visiting" for about 2 weeks and that they are planning to receive work permits within the next 2 weeks. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in continuing civil penalties. Immediate Civil Penalty Assessed today for $3,000.00 Exit interview conducted. A copy of this report, appeal rights provided and LIC421BG was given to Licensee/Administrator.
Regulation
(e) All individuals subject to a criminal record review...Health and Safety Code Section 1569.17(b) shall prior to working, residing in a licensed facility:
Inspector finding
Based on observation and interview the licensee did not comply with the section cited above in by not having fingerprint clearance for 6 (six) family relatives that are residing at the facility submitted to CCLD which poses a potential health, safety or personal rights risk to persons in care. Immediate Civil Penalty Assessed of $3,000.00
ComplaintJuly 17, 2024· UnsubstantiatedNo deficiencies
Inspector: Lori Alexander-Washington
Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.
Plain-language summary
A complaint alleged that staff refused to adjust the temperature in a resident's room during hot weather and removed his personal air conditioning unit without explanation. The investigation found conflicting accounts: the resident reported that a staff member refused his request to turn on the air conditioning, while staff stated they were willing to help but the resident had asked for cold air constantly; the resident said his personal AC unit was removed after a hospital stay without notice, but staff did not provide clear information about when or why this occurred. The inspector determined there was insufficient evidence to confirm whether violations took place.
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LIC9099-C Continued... LPA interviewed S1 that stated R1 wants the air to be cold and circulating all the time. S2 stated that R1 had a "private AC" but they took it out because it was expensive. S2 stated that R1's blinds are closed. S1 stated that on 07/09/2024 him and S2 were away from the facility but caregiver S3 was at the facility. S1 stated that he received a call from R1 regarding the temperature and that he spoke with S3. S1 stated that S3 said "...I don't know how to adjust the temperature..." S1 stated that he also spoke with his daughter, S4, who went and adjusted the temperature control. S1 stated when he returned back to the facility later that day, the temperature was good. LPA interviewed R1 that stated on 07/09/2024 his room was hot during the excessive heat conditions during the last couple of weeks. R1 stated that S1 was gone from the facility with guests and that he called S1 3 times that day and no answer. R1 stated that they requested to S3 if they could turn the air temperature on but S3 refused. R1 stated "I need a lot of air." R1 stated that they had their own "Energy Efficient" personal AC that included a fan and humidifier which was installed by W2 in their bedroom. R1 stated after he was discharged and returned back from his last hospitalization, 05/21/24 thru 05/28/24, his personal AC was gone without any notice or explanation to why it was removed. R1 stated that his room is hotter than all the other rooms in the house, the location where his room is facing and that there is no cross ventilation in his bedroom. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.
InspectionJune 18, 2024No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
This was a follow-up inspection on June 18, 2024, to verify that the facility had corrected violations from a previous inspection. The facility had not corrected a deficiency by the required deadline and was assessed a $600 civil penalty; the facility remains subject to daily penalties until the violation is fixed.
View full inspector notes
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.
Other visitMay 29, 2024Type B7 deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
During a routine annual inspection on May 29, 2024, inspectors found the facility's administrator certificate had expired in January 2024, though the administrator said he had submitted a renewal application in April. The facility itself was in good condition with safe temperatures, working smoke and carbon monoxide detectors, locked medications, and adequate food and lighting, but some required documents needed to be updated and submitted to the licensing agency by June 5, 2024.
View full inspector notes
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... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.
Regulation
(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.
Inspector finding
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 1 2 3 4 Administrator will submit all renewal certification documentation to CCLD by POC due date.
Regulation
(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 car…
Inspector finding
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 1 2 3 4 Administrator agree to submit R3's Physician's Report to CCLD by POC due date
Regulation
(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 physicia…
Inspector finding
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 1 2 3 4 Administrator agree to submit doctor's order for bed rails for R1 and R3 to CCLD by POC due date.
Regulation
(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.
Inspector finding
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 1 2 3 4 Administrator agree to submit a copy of letter sent to local fire dept for R1's oxygen use.
Regulation
(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.
Inspector finding
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 1 2 3 4 Administrator agree to submit a photo of signage on R1's door to CCLD by POC due date.
Regulation
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 specifi…
Inspector finding
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 1 2 3 4 Administrator agree to self-certify that they read the regulation and understand moving forward to comply with the regulations.
Regulation
87616 Exceptions for Health Conditions (b) Written requests shall include, but are not limited to, the following:
Inspector finding
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 1 2 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.
Other visitSeptember 11, 2023No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
On September 11, 2023, state licensing staff visited to follow up on documents requested three months earlier during the facility's annual inspection. The facility had not submitted updated liability insurance documentation by the deadline, and staff confirmed the facility did not have current liability insurance coverage. The facility was cited for these violations and warned that failure to correct them could result in penalties.
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On 09/11/2023 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Co-Administrator/Caregiver, Magdala D'Autruche, and explained the purpose of the visit. Back on 06/27/2023 during 1-Year Annual Required Inspection , LPA L. Alexander requested updated facility documents to be submitted by 07/04/2023. Administrator, Obed D'Autruche , failed to submit documents by requested due date. During phone call and interview LPA observed that the Administrator does not have current Liability Insurance. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided
Other visitAugust 2, 2023No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
This was a follow-up visit on August 2, 2023 to check whether the facility had corrected violations found during an annual inspection the previous month. The facility had not corrected three violations: missing physician reports, incomplete staff records, and no quarterly fire safety drills completed. The state assessed $2,700 in civil penalties and stated that penalties would continue until the violations were fixed.
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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... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.
InspectionJuly 19, 2023No deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
During a follow-up visit on July 19, 2023, inspectors checked whether the facility had completed corrections from a previous violation, reviewing client assessments and health screening records. No new deficiencies were found during this visit. The facility was given until July 24, 2023, to finish implementing the required corrections.
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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.
InspectionJune 27, 2023Type A49 deficiencies
Inspector: Lori Alexander-Washington
Plain-language summary
During a routine annual inspection on June 27, 2023, inspectors found multiple hazards: scissors, cleaning chemicals, and vitamins were left unlocked and accessible throughout the kitchen, pantry, and bathrooms, and a knife and scissors were found on the pantry floor. The facility also had not conducted any emergency disaster drills and had outdated emergency plan documentation. Other safety features including fire detectors, grab bars, and medication storage were in order.
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On 06/27/2023 at 11:10 AM, 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 4 Non-Ambulatory. 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 shared bedrooms are occupied by the residents and 3 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction except for side entry gate. There are no bodies of water observed. A comfortable temperature is maintained at 73 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 130.6 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 detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 04/04/2023. Emergency Disaster Plan was last posted on 02/08/2018. First aid kit was observed to be complete. Emergency disaster drill have not been conducted. LPA reviewed 3 residents records. LPA reviewed 7 staff records and 1 of 7 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications and it matched Medication Administration Record for R2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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. At 11:20 AM LPA observed 3 pairs of scissors unlocked in kitchen drawers At 11:22 AM LPA observed 5 bottles of vitamins unlocked in kitchen cabinet At 11:25 AM LPA observed bleach, Ajax Cleaner, disinfectant wipes unlocked under kitchen sink At 11:28 AM LPA observed a pair of scissors and cutting knife on the floor in unlocked pantry At 11:35 AM LPA observed Fabuloso Multipurpose Cleaner, Clorox Bleach and Mr. Clean Freak Spray in Shared bathroom# 2 At 11:45 AM LPA observed shower chair and microwave outside on side of house At 1146 AM LPA observed Masters pad lock on outside entry side gate Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/04/2023: 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.
Regulation
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having vitamins unlocked which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator removed the vitamins and locked up during visit. Deficiency cleared.
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having water temp at 133.4F which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator will adjust water temp and send photo to CCL by POC Due Date showing water temp
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having water temp 133.4 which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator will adjust water temp and send photo to CCL by POC Due Date showing water temp 105-120F
Regulation
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having scissors, viatmins, cleaning solutions inaccessible which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator removed and locked scissors, vitamins, cleaning solutions during visit. Deficiency cleared during visit.
Regulation
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by not having knives inaccessible to residents which poses an immediate health, safety risk to persons in care. POC Due Date: 06/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator removed knives and locked in toolbox with a new pad lock during visit. Deficiency cleared during visit.
Regulation
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (A) Section 87457, Pre-Admission Appraisal;
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having Pre-Admission Appraisal which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete and send a copy to CCLD by POC Due Date
Regulation
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after …
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having TB and Health Screenings for all staff which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator to schedule TB tests and Health Screening for all staff and send copies to CCLD by POC Due Date
Regulation
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having name, addresses, telephone numbers of resident's physicians and dentists on file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update records and submit a copy to CCLD by POC Due Date
Regulation
(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having Bedridden for R2 and R3 included in their plan which can pose a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update Plan of Operation for Bedridden. Administrator will send updated record for R3 in Shared Bedroom#2.
Regulation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by not having shower chair, microwave in outside back side yard accessible to residents in care which poses a potential health and safety risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will remove items and send a picture to CCLD by POC Due Date
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having Non-skid mats in Shared Bathroom#2 which posesa pote ntial health and safety risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will place non-skid mats in resident's bathroom and send a photo to CCLD by POC Due Date
Regulation
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having complete staff records maintained at the facility which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update all staff personnel records and send a copy of the names of all staff that records are complete along with a photo of all staff records to CCLD by POC Due Date
Regulation
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having each resident's records available, e.g., R3 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update resident's records and send a copy and/or pictures of R3's records
Regulation
(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having resident's records with physician's telephone numbers which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update and send a copy to CCLD by POC Due Date
Regulation
(b) Each resident's record shall contain at least the following information: (11) The documentation required by Section 87611(a) for residents with an allowable health condition.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having health condition for R3 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update and send a copy to CCLD by POC Due Date
Regulation
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having the appraisals completed for residents which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete appraisals and pre-appraisals and send copies to CCLD by POC Due date
Regulation
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (B) Section 87459, Functional Capabilities;
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having Functional Capabilities on file for residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete and submit a copy to CCLD by POC Due Date
Regulation
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (C) Section 87461, Mental Condition;
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having Mental Conditions for residents in care which posesa potent ial health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete and submit a copy to CCLD by POC Due Date
Regulation
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (E) Section 87463, Reappraisals; and
Inspector finding
Based on record review, the licensee did not comply with the section cited above in Reappraisals for residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete reappraisals and send a copy to CCLD by POC Due Date
Regulation
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having pre-admission appraisal for residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy of pre-admission appraisal to CCLD by POC Due Date and make sure that such appraisals are completed prior to admission for future residents
Regulation
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having on file an appraisal of individual service needs which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy to CCLD by POC Due Date
Regulation
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a Pre-Admission Appraisal for residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy of pre-admission appraisal to CCLD by POC Due Date
Regulation
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having signed Physicians Report for all residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy to CCLD by POC Due Date
Regulation
(b) The medical assessment shall include, but not be limited to:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having medical assessments for residents, R3 in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy to CCLD by POC Due Date
Regulation
(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 car…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having full diagnosis information on residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update and send a copy to CCLD by POC Due Date
Regulation
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or …
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having medical assessments of all residents in care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send copies to CCLD by POc Due Date
Regulation
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by having reappraisals for residents which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will do re-appraisals and send copies to CCLD by POC Due Date
Regulation
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will rece…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having meetings with residents and their reps which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will do re-appraisals and send copies to CCLD by POC Due Date
Regulation
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will rece…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by having meeting scheduled with residents and their reps which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will submit copies of updated meeting notes to CCLD by POC Due Date
Regulation
(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a copy of Admission Agreement which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete and send a photo to CCLD by POC Due Date
Regulation
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having resident registry roster completed and on file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete and send a copy to CCLD by POC Due Date
Regulation
(1) The resident's name and ambulatory status as specified in Section 87506(b)(1) and (b)(10).
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having R3's Medical Assessment on file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete a Medical Assessment and send to CCLD by POC Due Date
Regulation
(2) Information on the resident's attending physician as specified in Section 87506(b)(7).
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having R3's Medical Assessment which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will get Physician's Report for R3
Regulation
(3) Information on the resident's responsible person as specified in Section 87506(b)(6).
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having R3's information on file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will get R3's information and send copy to CCLD by POC Due Date
Regulation
(1) The register shall be treated as confidential information pursuant to Section 87506(c).
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having registry information of all residents which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will get ALL Resident's information and send copy to CCLD by POC Due Date
Regulation
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.
Inspector finding
Based on observation and record review, the licensee did not comply with the section cited above in by not having such plans available which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete plan and send a copy to CCLD by POC Due Date
Regulation
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having fire drills completed which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will conduct a fire drill with staff and have all staff sign-off that they participated and send a copy of fire drill to CCLD by POC Due Date
Regulation
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not reviewing plans annually. R2 has been at facility over a year and no review in file which posesa pote ntial health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update R2's file and send a copy to CCLD by Due Date
Regulation
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in noy having resident roster's completed which posesa potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete resident's roster and send a copy to CCLD by POC Due Date
Regulation
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having Appraisal Needs and Services Plans for residents which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will complete Appraisal Needs and Sevices for R1, R2 and R3 and send copies to CCLD by POC Due Date
Regulation
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility an…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by notifying CCL of R2's hospice care which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will submit Initiation of Hospice Services for R2 to CCLD by POC Due Date
Regulation
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having hospice care plan for R2 in their file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy of hospice care plan to CCLD by POC Due Date
Regulation
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (1) The name, office address, business telephone number, and 24-hour emergency telephone number of the hospice agency and the resident's physician.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a complete hospice care plan for R2 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will submit a copy to CCLD by POC Due Date
Regulation
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physic…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a hospice care plan for R2's file which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will send a copy to CCLD by POC Due Date
Regulation
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physic…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having a complete hospice care plan for R2 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will submit hospice care plan to CCLD by POC Due Date
Regulation
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures fo…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having in the resident's files an advanced directive which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update and send a copy to CCLD by POC Due Date
Regulation
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her ack…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having R2's acknowledgement to receive hospi ce care and R3's agreement to shared living space which posesa potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update the records and file documents. Administrator will send a signed copy to CCLD by POC Due Date
Regulation
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in by not having R2's appraisals/reappraisals completed which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will update resident's appraisals and send a copy to CCLD by POC Due Date
Regulation
Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in by having a Masters pad lock on entry gate and a piece of tree trunk wood placed on the outside side entry gate which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/11/2023 Plan of Correction 1 2 3 4 Administrator will fix/repair the side entry gate to where there will be a latch to keep the side entry gate closed. Administrator will send a photo to CCLD by POC Due …
InspectionMay 12, 2022Type A2 deficiencies
Inspector: Carol Fowler
Plain-language summary
This was a routine infection control inspection in May 2022. Inspectors found multiple safety hazards throughout the facility, including scissors left on a piano bench, an unlocked knife on the stove, cleaning chemicals stored in an unlocked laundry room, and garden tools and ladders accessible in the backyard. The facility was also cited for not maintaining visitor and temperature logs.
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On 05/12/2022 at 2:20 pm, Licensing Program Analyst (LPA) C. Fowler and arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Obed D'Autruche and explained the purpose of the visit. Upon entry, LPA observed screening station that contained hand sanitizer and thermometer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPA did not observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan and provided LPA with a copy via email. The following deficiencies were observed during the visit: -At 2:44pm, LPA observed a pair of scissors on the piano bench located in the living room. -At 2:52pm, LPA observed a knife on top of the stove in the kitchen unlocked, knives are kept in unlocked drawer. -At 2:53pm, LPA observed All laundry soap, Downy fabric softener, bleach, Pine clean, Lyson spray, Fauloso, Windex, WD-40, and Mr. Clean in a unlocked laundry room. -At 2:59pm, LPA observed a rake, garden tools, bed rails, 2 ladders located in the back yard. Continued on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Request updated documents The following forms are to be updated and submitted to CCLD by 5/19/2022. -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility -LIC610E Emergency Disaster Plan ARF LIC610D Exit interview conducted. A copy of this report and appeal rights provided.
Regulation
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning suppli…
Inspector finding
Based on observation the licensee did not comply with the section cited above by having laundry room unlocked with cleaning supplies listed above and garden tools bed rail and 2 ladders accessible to residents which poses an immediate health and safety risk to persons in care. POC Due Date: 05/13/2022 Plan of Correction 1 2 3 4 Administrator locked the laundry room door with the cleaning products and put garden tools, ladder, and bed rail in the locked garage. Deficiency cleared during visit.
Regulation
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Inspector finding
Based on observation the licensee did not comply with the section cited above by storing knives in an unlocked drawer which poses an immediate health and safety risk to persons in care. POC Due Date: 05/13/2022 Plan of Correction 1 2 3 4 Administrator agreed to purchase a lock for the kitchen draw/cabinet and keep the knives locked. Administrator will email photo copies to CCLD no later then the POC date,
Other visitApril 28, 2022Type B1 deficiency
Inspector: Leslie Ibo
Plain-language summary
During an unannounced visit on April 28, 2022, inspectors found that the facility failed to file a required incident report about a bed bug problem that had occurred months earlier. Inspectors provided training on incident reporting requirements, COVID-19 safety protocols, and visitor screening procedures, and the administrator agreed to comply with state regulations going forward. A deficiency was cited for the failure to report the incident.
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On 4/28/2022, while at the facility for another reason, Licensing Program Analysts (LPAs) L. Ibo and K. Nguyen conducted an unannounced case management visit and met with Administrator OBED D'AUTRUCHE. Administrator admitted that he did not submit incident report regarding bed bugs few months ago. LPAs explained the importance of completing the Incident Report for each occurrence regarding each resident and submitting the written LIC 624 to CCL within 7 seven days. Serious incidents will need to be reported within 24 hours to CCL, Ombudsman, Police and authorized representative as required. LPAs conducted technical assistance with the following topics but not limited to; covid19 posters needs to be posted at the front door and common areas at the facility, covdi19 screening station with logs for all visitors, residents and staff and hand sanitizer should always be available at the front entrance. Administrator stated they will comply with Title 22 regulations regarding reporting requirements. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC-9099 D. Failure to submit proof of correction (POC) by plan of correction due date or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of this report provided.
Regulation
Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement was not met as evidence by:
Inspector finding
Based on investigation, licensee did not comply with the section cited above by not submitting incident report regarding bed bugs at the facility which poses a potential health and safety risk to the residents in care.
ComplaintApril 28, 2022· SubstantiatedType B1 deficiency
Inspector: Leslie Ibo
Plain-language summary
This was a complaint investigation that found violations at the facility. The investigator met with management to discuss the deficiencies and provided notice of the corrections required. The facility must submit proof that it has fixed these issues by the deadline stated in the official notice.
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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with OBED D'AUTRUCHE. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided Administrator.
Regulation
87303 (a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
Inspector finding
Based on interview and inspection, the Administrator failed to ensure the facility is free of pest which poses potential health and safety risks to residents in care. Administrator admitted that there were bed bugs at the facility couple of months ago.
ComplaintJune 30, 2021Type B1 deficiency
Inspector: Lizette Francisco
Plain-language summary
During an unannounced infection control inspection on June 30, 2021, inspectors found that the facility was not conducting COVID-19 testing for staff, which violated state regulations; the facility otherwise had adequate food supplies, proper screening procedures at entry, accessible personal protective equipment, and staff were observed wearing appropriate protective gear. The facility was given a deadline to correct this deficiency and was warned that failure to do so could result in additional penalties.
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On 6/30/2021 starting at 8:55AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA met with Administrator, Obed D'Autruche and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A thermometer and temperature log book were observed at screening station. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. At 9:45am, LPA observed no current COVID-19 testing for staff were on file. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.
Regulation
87405(d)(2) Administrator Qualification and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
Inspector finding
Based on interview and record review, Licensee did not comply with the section cited above. LPA observed facility has not completed COVID-19 testing for staff in accordance to Local County guidelines which poses a potential health and safety risk to residents in care. POC Due Date: 07/09/2021 Plan of Correction 1 2 3 4 By POC date, Administrator agrees to complete COVID-19 test for each staff in accordance to Local County guidelines and send a copy of results to CCL by POC date.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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