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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:59:24 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
08/20/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240820101350
FACILITY NAME:OPAL CARE LLCFACILITY NUMBER:
019200672
ADMINISTRATOR:PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:15CENSUS: 13DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jezrael Pascual/Victoria PurugananTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not provide itemized billing statement to responsible person
INVESTIGATION FINDINGS:
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On this day at around 9:50 am, LPAs Luisa Fontanilla and David Doidge arrived at the facility to conduct investigation on the above allegations and met with House Manager Jezrael Pascual. LPAs explained to Pascual the purpose of the visit. Administrator Victoria Puruganan arrived at a later time.

During the course of investigation, LPAs reviewed 4 resident records including but not limited to admission agreement, Physician's Report, Emergency Information, Register of Residents, Lic 500 and interviewed the Administrator and House Manager. LPAs interviewed R1, R3 and R4.

Facility staff did not provide itemized billing statement to responsible person

During the visit, LPAs obtained and reviewed a copy of the facility's admission agreement. LPAs observed the facility is using a revised admission agreement that does not meet the requirements. It does not ***continuation on lic 9099C***

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 5
Control Number 15-AS-20240820101350
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: 08/28/2024
NARRATIVE
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indicate itemized charges as required in the admission agreement that was approved by the Department.

Based on record review conducted, the above allegation is substantiated.

Based on LPAs observations and record reviews conducted, 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 9099D.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240820101350
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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87507(a)
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87507 Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
This requirement is not met as evidenced by:
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By POC date, the Administrator will review section 87507 Admission Agreement and will submit to CCL the following: 1) understanding of the section 2) self-certification stating that effective immediately, the approved admission agreement will implemented.
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Based on record review conducted, the facility did not have an admission agreement that is compliant to the section cited. The facility is using a revised form that is not approved by the department and is missing required itemized charges which poses a potential risk to the health and safety of clients under care.
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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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/20/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240820101350

FACILITY NAME:OPAL CARE LLCFACILITY NUMBER:
019200672
ADMINISTRATOR:PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:15CENSUS: 13DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jezrael PascualTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Illegal eviction
Facility staff did not dispense medications as prescribed
Facility staff did not properly supervise resident resulting in resident wandering away from facility
Facility staff did not provide written copy of admissions agreement to responsible person
INVESTIGATION FINDINGS:
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On this day at around 9:50 am, LPAs Luisa Fontanilla and David Doidge arrived at the facility to conduct investigation on the above allegations. LPAs met with Administrator Victoria Puruganan and House Manager Jezrael Pascual. LPAs explained to the Administrator/House Manager the purpose of the visit.

During the visit, LPAs reviewed records and conducted interviews.

Illegal eviction
Based on interviews conducted with the Administrator and House Manager, no resident has been issued an eviction notice. There are two residents who live on the 2nd floor that neeed to be moved due to fire clearance violation of the facility. The Administrator states one resident (R2) has voluntarily moved to Hartnell Care Home on 8/23/2024. The other resident (R 1)has dementia but is physically independent with ADLs.

continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240820101350
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: 08/28/2024
NARRATIVE
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Facility staff did not dispense medications as prescribed
During interview, the House Manager explained to the LPAs procedure when giving medications to the residents. House Manager also states that staff giving medications make sure that the residents take their medications. Residents interviewed state they get all their medications on time.

Facility staff did not properly supervise resident resulting in resident wandering away from facility
During interview conducted, the Administrator and House Manager state the facility has an auditory device that gets turned off during the day and turned on at night. During the day when the alarm is off, staff monitor the residents. The Administrator will install additional auditory device (Ring) by tomorrow, 8/29/2024.

While at the facility, LPAs observed a staff watching over the residents in the front yard. The facility's last AWOL was recorded on 7/21/2023.

Facility staff did not provide written copy of admissions agreement to responsible person.
Based on interviews conducted, the Administrator states after admissions agreement are signed, a copy has always been given to the resident's responsible person.

During the visit, LPAs interviewed Housing Authority of the County of Alameda (HACA) Supervisor (W1) who states that the office has a copy of all the clients' admission agreements.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted with the Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5