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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200068
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:15:57 PM

Document Has Been Signed on 10/25/2022 02:15 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
E BAY DELTA AC/SC, 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: 10DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Chandra Jackson, Program CoordinatorTIME COMPLETED:
02:25 PM
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On 10/25/2022 starting at 12:35 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Program Coordinator and disclosed the purpose of the visit.

Upon entry, LPA’s temperature was checked and asked to fill out Covid-19 questionnaire. LPA toured facility including but not limited to screening station, hand washing stations, bathrooms, activities rooms, and common areas. There is one central entry point for universal screening for staff, clients, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility didn't provide meals and manage medication. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. Facility will provide an updated Emergency Disaster Plan (LIC610E) to CCL by 11/1/2022.

No deficiency cited during visit. Exit interview conducted with Program Coordinator and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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