011400128-8-23-2022-15-AS-KHOS-CHMNMW-20220825103548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400128
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:27:46 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
03/29/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220329092717

FACILITY NAME:	CLAUSEN HOUSE-ADULT RES. FACILITY		FACILITY NUMBER:	011400128
ADMINISTRATOR:	BRANDY HARPER		FACILITY TYPE:	735
ADDRESS:	88 VERNON STREET		TELEPHONE:	(510) 839-0050
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	15	CENSUS: 10	DATE:	08/23/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Veronica Mercado Santana, Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Resident's medications are mismanaged.
Residents are not adequately fed.
Staff member yelled at resident.
Staff member inappropriately spoke to resident.

INVESTIGATION FINDINGS:

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On 8/23/2022 at 8:30 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA explained the purpose of the visit with administrator (AD).

Allegation - Resident's medications are mismanaged – Unsubstantiated.
The Department has investigated this allegation and per records review and interviews, and found that R4’s Medication Administration Records (MAR) indicated that 2 days of medication (Fluvoxamine 100mg tablet) were missed on 3/12/22 and 3/13/22 because medication was handed by R4’s family member who didn’t pass medication to facility, AD communicated with R4’s family member and called pharmacy to refill it on 3/12/22, and documented it on MAR. R5’s MAR indicated that 1 day of medication (Fexofenadine 180mg tablet) was

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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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Control Number 15-AS-20220329092717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CLAUSEN HOUSE-ADULT RES. FACILITY	FACILITY NUMBER: 011400128
	VISIT DATE: 08/23/2022

NARRATIVE

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missed on 03/12/22 because refill was handled by family member who didn’t manage it timely, AD communicated with family member and received refill on 3/14/22, and documented it on MAR. No record indicated that missing medication was resulted by staff member.

Allegation - Residents are not adequately fed – Unsubstantiated

The Department has investigated this allegation and per records review and interviews, residents stated that they were fed well in both quantity and quality. 6 Residents claimed that there was always food and they never felt hungry. Staff S1 and S2 stated that they always saw plenty of food for residents in facility. Omelet, pancake, bread, cereals, and milk were observed for breakfast in both visits on 4/1/22 and 8/10/22, ham sandwiches and salad were observed for lunch on 8/10/22.

Allegation - Staff member yelled at resident – Unsubstantiated

The Department has investigated this allegation, and per records review and interviews found that the above allegation was not observed or witnessed by 3 staff and 6 clients who have been interviewed.

Allegation - Staff member inappropriately spoke to resident – Unsubstantiated

Based on observation, records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations 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 allegations are unsubstantiated.

No deficiency cited, exit interview conducted with administrator, and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC9099 (FAS) - (06/04)

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