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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:10:03 PM


Document Has Been Signed on 10/24/2024 12:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 12DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jezrael Pascual Office ManagerTIME COMPLETED:
01:00 PM
NARRATIVE
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On 10/24/2024 at 10:00 AM, Licensing Program Analysts (LPAs) D. Doidge and A. Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Jezrael Pascual Office Manager and explained the purpose of the visit.

LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 107 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/01/2024. Emergency Disaster Plan was last posted on 06/06/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/07/2024.

LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. The following reports were reviewed: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate.

At 10:38 AM, LPAs inspected the shared bathroom and observed no lids on trash cans.

The above deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22and/or health safety Code failure to correct deficiency by POC date may result in additional civil penalties.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David DoidgeTELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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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Document Has Been Signed on 10/24/2024 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(4)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as trash bins in shared bathrooms were uncovered which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Provide coverd trash bins for shared bathrooms and provide photos to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David DoidgeTELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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