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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401135
Report Date: 11/05/2024
Date Signed: 11/05/2024 01:56:56 PM

Document Has Been Signed on 11/05/2024 01:56 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/
DIRECTOR:		VERONICA MERCADO-SANTANAFACILITY TYPE:
735
ADDRESS:363 BELMONT STTELEPHONE:
(510) 839-0050
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 11CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Veronica Mercado-Santana, Adminsitrator TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 11/05/2024 at 01:05PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced at the above location to conduct a health and safety check and to visit the temporary relocation of the residents from Clausen house-Adult Res. Facility (11400128). LPA meet with administrator Veronica Mercado-Santana and explained to her the reason for the visit.

S1 stated that four residents were relocated to the Belmont location on 11/1/24, one resident was with family over the weekend and was relocated on 11/4/24. S1 stated that the rest of the residents from Vernon would be relocated to the Belmont location once furniture is delivered on 11/8/24. S1 has had two contractors visit the facility on Vernon and is waiting for the engineer from the insurance for the final say on what is happening with that location.

Exit interview was conducted. A copy of this report was provided. No deficiencies observed or cited during this visit.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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