011401135-8-20-2021-15-AS-CLIN-C643FH-20210820181247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011401135
Report Date: 08/20/2021
Date Signed: 08/20/2021 06:12:57 PM

Document Has Been Signed on 08/20/2021 06:12 PM - 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		FACILITY NUMBER:	011401135
ADMINISTRATOR:	STACIA OLIVIER		FACILITY TYPE:	735
ADDRESS:	363 BELMONT ST		TELEPHONE:	(510) 763-3598
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY: 11		CENSUS: 5	DATE:	08/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Claudia Uribe-Lopez Acosta, Manager		TIME COMPLETED:	06:20 PM

NARRATIVE

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On August 20, 2021, at 3:45am, Licensing Program Analysts (LPAs) Catherine Lin and Alicia Delmundo conducted an unannounced annual required/infection control inspection, and met with staff member Candida Peralta, and informed the purpose of visit. LPAs were granted entry into the facility by Candida. Candida called Claudia Acosta, manager. LPAs also met with Carlos Lainez, in-house maintenance manager.

Candida and Carlos accompanied LPAs inside and out the during inspection. Claudia arrived facility at 4:10 p.m.

LPAs observed screen table is by the entrance. Check-in process is in place.

LPA inspected the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives, medication and toxic were kept in locked storage cabinet. Fire extinguisher checked, observed fully charge and last serviced January 21, 2021. Carbon monoxide and smoke detector tested and observed working. PPE and other paper supplies are sufficient. Facility has sprinklers which according to Carlos is inspected every 5 years.

.......Continue writing narrative on LIC809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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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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	FACILITY NUMBER: 011401135
	VISIT DATE: 08/20/2021

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LPAs verified and Claudia stated she took over the position of administrator end of June, 2021; however, upon further verification, Claudia stated she has completed the initial 35 hours initial certification and is working on being a certified administrator. LPA Delmundo spoke with Jaynette Underhill who indicated that she will be the interim administrator while Claudia is working on her administrator certificate.

During the inspection, LPA observed the following:

Some trash bins with no lids.
Facility has not completed the N95 fit testing for staff.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 months may result in civil penalties.

Exit interview conducted. Plan and proof of correction were reviewed and developed with Claudia Acosta. Copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2021 06:12 PM - It Cannot Be Edited

Created By: Catherine Lin On 08/20/2021 at 05:49 PM

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	FACILITY NUMBER: 011401135
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81061(j)

81061 REPORTING REQUIREMENTS (j) The licensee shall notify the licensing agency, in writing, within 10 working days of a change of administrator or program director. Such notification shall include the following This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview, the licensee did not comply with the section cited above for not reporting to Community Care Licensing the change in administrator which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2021
	Plan of Correction
1 2 3 4	Licensse to submit the following by POC date: 1. Board Resolution indicating the change in administrator 2, Copy of Jaynette Undehill's administrator certificate 3. Copy of LIC501 Personnel Record

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC809 (FAS) - (06/04)

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