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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400128
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:29:23 AM

Document Has Been Signed on 08/23/2022 10:29 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
E BAY DELTA AC/SC, 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: 10DATE:
08/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Veronica Mercado Santana, AdministratorTIME COMPLETED:
10:45 AM
NARRATIVE
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On 8/23/2022 approximately at 10:00 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted case management, met with Administrator (AD), and explained the purpose of visit.

During the course of investigation on a complaint, the Department observed residents’ Centrally Stored Medication Records were incomplete or not found before the month of March 2022. AD stated that she took over the position on 3/11/22 and couldn’t locate the previous medication records, former AD left facility in sudden situation and was unable to be reached.

Deficiency is cited per Title 22 California Code of Regulations. Please refer to LIC 809D.

Exit interview was conducted with Administrator, Appeal Rights and a copy of report were 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
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 08/23/2022 10:29 AM - It Cannot Be Edited


Created By: Catherine Lin On 08/23/2022 at 10:07 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
, 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: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80075(k)(7)

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80075 Health Related Services
(k)The following requirements shall apply to medications which are centrally stored:
(7)The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year….
This requirement is not met as evidenced by:
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Administrator agreed to create a medication training curriculum, and write a self-certification to train staff and maintain in-service training record in facility, submit curriculum and self-certification to CCL by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed residents’ Centrally Stored Medication Records were incomplete or not found before the month of March 2022, which posed a potential health, safety or personal rights risk to persons in care.
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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: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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