019200672-8-4-2023-15-AS-KHOS-CURR8Q-20230816124820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:50:35 PM

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
07/31/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230731091529

FACILITY NAME:	OPAL CARE LLC		FACILITY NUMBER:	019200672
ADMINISTRATOR:	PURUGANAN, VICTORIA		FACILITY TYPE:	740
ADDRESS:	3917 OPAL STREET		TELEPHONE:	(510) 420-0731
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	15	CENSUS: 14	DATE:	08/04/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jezrael Pascual/House Manager		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Insufficient staff to meet resident needs.

INVESTIGATION FINDINGS:

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At 11:30 am on this day, August 4, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with House Manager Jezrael Pascual, and informed the purpose of visit. LPA called, and spoke over the phone with Victoria Puruganan, administrator, who stated she can not come to the facility, and authorized Jezrael Pascual to sign, and receive this report.

LPA obtained copy IC500 Personnel Report, reviewed residents' records and conducted interviews.

LIC500 showed the following:
-during the day there are only 2 care staff scheduled which includes the house manager from 8:00 am to 3:30 pm.
-house manager scheduled from 8:00 am to 5:00 pm.
-1 staff scheduled from 7:00 am to 8:00 am.
-NO awake staff scheduled from 11:00 pm to 7:00 am.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230731091529

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: OPAL CARE LLC	FACILITY NUMBER: 019200672
	VISIT DATE: 08/04/2023

NARRATIVE

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Review of records showed 2 residents have wandering behavior, another resident AWOLed last month, and LIC500 showed no awake/night staff. LPA interviewed 4 staff who confirmed there's no awake night staff and only 1 staff scheduled from 5:00 pm to 11:00 pm.

Based on information gathered, the preponderance of evidence has been met, therefore, the allegation of insufficient staff to meet resident needs is substantiated.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the administrator over the phone in the presence of the house manager.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230731091529

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: OPAL CARE LLC	FACILITY NUMBER: 019200672
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/18/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary to perform office work, cooking, house cleaning,.....	1 2 3 4 5 6 7	Administrator to hire additional staff, and submit copy of LIC500 Personnel Report by 8/18/23.
	8 9 10 11 12 13 14	...laundering, and maintenance of buildings, equipment and grounds. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not having sufficient staff which poses a potential safety and personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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