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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400128
Report Date: 10/28/2021
Date Signed: 11/02/2021 08:28:47 AM

Document Has Been Signed on 11/02/2021 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CLAUSEN HOUSE-ADULT RES. FACILITYFACILITY NUMBER:
011400128
ADMINISTRATOR:BRANDY HARPERFACILITY TYPE:
735
ADDRESS:88 VERNON STREETTELEPHONE:
(510) 839-0050
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 15CENSUS: 13DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Brandy Harper, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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On 11/0202021, at 8:02AM, Licensing Program Analysts (LPAs) C. Lin and D. Panlilio arrived unannounced to deliver the amendment to an original 809 report created on 10/28/21. LPAs met with administrator and explained the purpose of the visit.

On 10/28/2021 starting at 8:00AM, Licensing Program Analysts (LPA) C. Lin and arrived unannounced to conduct a required Annual Visit and Infection Control Inspection. There were no staff at the facility. LPA called and spoke to Administrator, who arrived at the facility at 8:36AM.

During the Infection Control Inspection, LPA toured facility including but not limited to front and back entrances, screening station, bedrooms, kitchen and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 8:00AM, LPA observed there has no staff supervision for clients in care at the facility between 8:00AM and 8:36AM. LPA found that the overnight staff person had left at 8:00 am, and no other care staff were present until the arrival of the Administrator at 8:36AM.
· At 8:45AM, LPA observed unlocked knives and cleaning supplies in two separated cabinets located in the hallway where were accessible to clients. Locks were broken. Maintenance person replaced with new locks during inspection.

The following 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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2021 08:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/01/2021 05:02 PM


Created By: Catherine Lin On 10/28/2021 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLAUSEN HOUSE-ADULT RES. FACILITY
FACILITY NUMBER: 011400128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80078(a)


This requirement is not met as evidenced by:

80078 Responsibility for Providing Care and Supervision

(a)The licensee shall provide care and supervision as necessary to meet the client's needs.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above.LPA found that there were no care staff present between 8:00 am and 8:36 am which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Administrator agreed to provide a copy of update staff schedule, and ensure staff needs to be in the facility for supersivion at all time.

Deficiency cleared. Administrator provided updated staff schedule during visit.
Type A
Section Cited
CCR
80087(g)(1)
This requirement is not met as evidenced by:

80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked knivies and cleaning supplies in cabinets located in hallway where were accessible to clients which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Administrator agreed to replace broken locks for two cabinets where contains knivies and cleaning supplies.

Deficiency cleared. Administrator have the maintenance staff replaced with new locks on cabinets during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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