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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 10/14/2021
Date Signed: 10/14/2021 05:08:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 9DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Victoria Puruganan, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 10/14/2021 starting at 1:53PM, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff Marietta Nicolas and explained the purpose of the visit. Administrator Victoria Puruganan arrived at 3:03PM.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a mitigation plan and emergency disaster plan on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
ยท At 2:05PM, LPA observed a person who was working has no fingerprint clearance. She has been working at facility since Monday 10/11/21, 4 days in total.


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. A person who works at facility did not have background check clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Administrator agrees to provide self-certification to CCL by POC date. Deficiency cleared during visit.

Civid Penalty $400 is assessed.
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) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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