019200672-4-10-2024-15-AS-KHOS-D8CJE8-20240821065837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:19:27 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
04/05/2024 and conducted by Evaluator Gregory Clark

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240405092549

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: 12	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jezrael Pascual, House Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Licensee does not ensure facility has night staff to care and supervise residents.

INVESTIGATION FINDINGS:

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On 4/10/24 at 11:00 am, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to an initial 10-day complaint investigation in regard to the allegation above. LPA met with House Manager Jezrael Pascual, and informed the purpose of visit.

LPA obtained copy of the current staff schedule 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.

***report continjes on LIC9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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-20240405092549

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: 04/10/2024

NARRATIVE

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***report continues from LIC9099***

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Civil penalty in the amount of $500 assessed for repeat violation.

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240405092549

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: 04/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/17/2024 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 awake night staff. Administrator will submit copy of LIC500 Personnel Report To CCL by 4/17/24.
	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	Immediate Civil Penalty of $500 is being assessed today for 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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