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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200068
Report Date: 04/25/2022
Date Signed: 04/25/2022 02:04:32 PM

Document Has Been Signed on 04/25/2022 02:04 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 ADULT EDUCATION PROGRAMFACILITY NUMBER:
019200068
ADMINISTRATOR:SHAWN EDWARDSFACILITY TYPE:
775
ADDRESS:650 GRAND AVETELEPHONE:
(510) 208-4659
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 65CENSUS: 27DATE:
04/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Chandra Jackson, Program CoordinatorTIME COMPLETED:
02:15 PM
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On 04/25/2022 at approximately 9:05am Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a case management of Health and safety check for Covid related. LPA met with Program Coordinator Chandra Jackson and explained the purpose of the visit.

During the visit, LPA obtained 4 participants' ISP, Covid Assessment reports, and facility polity. and interviewed staff. LPA observed that facility followed the protocol of indoor masking required by Alameda Public Health and the CCL mitigation plan.

No deficiency cited during visit. Exit interview conducted with Program Coordinator and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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