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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011401330
Report Date: 12/14/2022
Date Signed: 12/14/2022 09:31:17 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
09/20/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220920080444
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: 6DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Veronica Mercado Santana, AdministratorTIME COMPLETED:
09:40 AM
ALLEGATION(S):
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Staff does not ensure the needs of the client are being met
INVESTIGATION FINDINGS:
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On 12/14/22 at 8:20am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and delivered investigation findings. LPA met with Administrator and explained the purpose of the visit.

The Department has investigated this allegation and per records review and interviews found that the facility Administrator (AD) made affords to assist client C1 to replace his identification and medical cards that were lost as noon as AD knew it from C1’s case manager (W4) in July 2022. W4 stated that C1 has never shared that ID and medical cards were lost before. W4 stated that she has been working with facility AD to assist C1, however, C1 did not cooperate with AD and W4 to replace cards. C1 left facility before 6am and came back to facility late most of the time.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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-20220920080444
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CLAUSEN HOUSE
FACILITY NUMBER: 011401330
VISIT DATE: 12/14/2022
NARRATIVE
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Another alleged violation was that C1 was locked out of facility. AD and staff denied it. C1’s case manager W4 and relatives W2 and W3 were not aware of this incident. C1 was confused about this incident. Clients C2, C3, C4, C5, and C6 stated that staff always opened the door whenever they came home, and have not witnessed that C1 was locked out of facility.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2