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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401135
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:35:51 PM

Document Has Been Signed on 12/11/2023 03:35 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 HOUSEFACILITY NUMBER:
011401135
ADMINISTRATOR:VERONICA MERCADO-SANTANAFACILITY TYPE:
735
ADDRESS:363 BELMONT STTELEPHONE:
(510) 839-0050
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 11CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Veronica Santana, Sr. Director of ProgramsTIME COMPLETED:
03:45 PM
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On 12/11/23 Licensing Program Analyst (LPA) Greg Clark arrived unannounced to continue 1-Year Annual Required inspection. LPA met with Administrator, Veronica Santana and explained the purpose of the visit. The facility’s fire clearance was approved for 11.

During the visit LPA reviewed 5 resident records and all were complete. LPA also reviewed the Emergency Disaster Plan (LIC610E).

Updated copies of the following document was requested for facility file and are to be submitted to CCL by 12/18/23: LIC 610E Emergency Disaster Plan

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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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