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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011401135
Report Date: 01/06/2023
Date Signed: 02/02/2023 01:37:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2021 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20210504094250
FACILITY NAME:CLAUSEN HOUSEFACILITY NUMBER:
011401135
ADMINISTRATOR:STACIA OLIVIERFACILITY TYPE:
735
ADDRESS:363 BELMONT STTELEPHONE:
(510) 763-3598
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:11CENSUS: 5DATE:
01/06/2023
UNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Veronica Santana, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff did not keep resident's personal information confidential
Staff did not give resident copies of incident reports he filed
INVESTIGATION FINDINGS:
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***This is an amended report***

On 1/06/23 at 11:05 AM, Licensing Program Analyst (LPA) G. Clark arrived unannounced to deliver findings for the above allegations. LPA met with Administrator, Veronica Santana and explained the purpose of the visit.

It was alleged staff did not keep resident’s personal information confidential. Based on information obtained by complainant, a copy of the eviction notice was placed on C1’s desk. It was confirmed by S1 a copy of the 30-day eviction notice was given to C1 and a copy was placed in C1’s room. However, LPA was unable to determine whether C1’s roommate had access. LPA was unable to prove or disprove the allegation.

***Report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20210504094250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 011401135
VISIT DATE: 01/06/2023
NARRATIVE
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***Report continues from LIC9099***

It was alleged staff did not give resident copies of incident reports C1 filed. However, based on interview with S1, S1 stated that all documents and incident reports were provided to C1. Due to conflicting information, LPA was unable to prove or disprove allegation.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2