019200672-10-5-2023-15-AS-KHOS-CY2RN4-20231129120940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:14:18 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
09/29/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230929092934

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: 15	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Jezrael Pascual/House Manager		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Insufficient staff to meet resident needs

INVESTIGATION FINDINGS:

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On 10/5/2023 at 8:21 am, Licensing Program Analyst (LPA) J Clancy-Czuleger 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 of the current staff schedule, reviewed residents' records and conducted interviews.

The staff schedule showed the following:
-during the day there are only 2 care staff scheduled from 7:00 am to 3:30 pm.
-house manager scheduled from 8:00 am to 5:00 pm.
-1 staff scheduled from 3:00 pm to 11:00 pm.
-NO awake staff scheduled from 11:00 pm to 7:00 am.
Continued on LIC 9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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 3

Control Number 15-AS-20230929092934

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: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/19/2023 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...-This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to hire one additional daytime staff, and one over night staff. The facility will submit copy of LIC500 Personnel Report by 10/19/23.
	8 9 10 11 12 13 14	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	Civil penalty of $250 is being assess for a repeat violation.
	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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230929092934

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: 10/05/2023

NARRATIVE

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...Continued from LIC 9099

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 9099-D. Civil penalty in the amount of $250 assessed for repeat violation.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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