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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011401330
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:47:14 AM

Substantiated


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
10/25/2021 and conducted by Evaluator Grace Luk
COMPLAINT CONTROL NUMBER: 15-AS-20211025143344
FACILITY NAME:CLAUSEN HOUSEFACILITY NUMBER:
011401330
ADMINISTRATOR:YAMINAH HOLMESFACILITY TYPE:
735
ADDRESS:201 PERKINS STREETTELEPHONE:
(510) 839-0050
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:11CENSUS: 10DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Claudia Acosta, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility roof is in disrepair
Facility bathtub is in disrepair
INVESTIGATION FINDINGS:
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On 11/2/2021 at 9:06AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation in regards to the allegations above. LPA met with Administrator, Claudia Acosta and informed her about the allegations.

During the course of investigation, LPA interviewed clients and staff. LPA toured the facility and observed the roof was leaking in two bedrooms. LPA also observed that the sliding glass door of the bathtub was broken where the glass swings out. Interviews with clients and staff indicated that the two bedrooms had water leakage when raining and the plastic part of the sliding glass door was broken.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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-20211025143344
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: 011401330
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
80087(a)
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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients... This requirment is not met as evidence by:
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Administrator has agreed to fix the roof and bathtub sliding glass door. Administrator will submit picture proof of correction by POC date.
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Based on investigation, licensee did not comply with the section cited above by having dispaired roof and bathtub sliding glass door which poses a potential health and safety risk to the clients 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2