019200672-10-21-2022-15-AS-CLIN-CKEU2M-20221021151211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:12:30 PM

Document Has Been Signed on 10/21/2022 03:12 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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: 14	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Jezrael Pascual, House Manager		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/21/2022 starting at 12:20 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with House Manager and disclosed the purpose of the visit. LPA spoke with Administrator Victoria Puruganan on the phone and authorized the house manager to sign on the report. During the Infection Control Inspection, LPA 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 Mitigation Plan and maintains record of routine screening for residents, staff and visitors. THE FOLLOWING DEFICIENCIES WERE OBSERVED: · At approximately 12:30 p.m., LPA observed a basket of medication on the desk in the office and office was widely opened, also observed centrally stored medications was unlocked and key was left on the lock. Staff locked up but later found out she didn't have the key. Another staff brought in the key and took a while to open it. · At approximately 12:40 p.m., LPA observed a closet with disinfectants where is between living and dining room was unlocked, cleaning supply under the sink in the bathroom on the 2nd floor was unlocked, shed with power tools in the backyard was unlocked, laundry room with laundry detergents inside the room was unlocked. House manager locked up all items during inspection. Continue on LIC809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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 10/21/2022 03:12 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OPAL CARE LLC	FACILITY NUMBER: 019200672
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 heater vents on the 2nd floor were disrepair which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	The house manager agrees to fix the heater vents and send picture to CCL by the POC due date.

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above, water temperature was 142 degree F in bathroom which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	The house manager turned the water temperature down during visit. House manager agrees to maintain water supplies in compliance.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OPAL CARE LLC	FACILITY NUMBER: 019200672
	VISIT DATE: 10/21/2022

NARRATIVE

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· At approximately 12:45 p.m., LPA observed 2 heater vents on the 2nd floor were disrepair.
· At approximately 1:00 p.m., LPA observed water temperature in bathroom was 142 degree F. House manager turned down the temperature during inspection.

House manager agrees to update an Emergency Disaster Plan (LIC 610E), infection control plan with monkeypox, and submits to LPA by 10/28/22.

The above deficiencies were 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 with house manager and discussed with Administrator on the phone. LIC809D, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 10/21/2022 03:12 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OPAL CARE LLC	FACILITY NUMBER: 019200672
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above, cleaning supplies in the bathroom and closet, power tools in the shed in the backyard, and laundry detergent in the laundry room were accessible to residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2022
	Plan of Correction
1 2 3 4	The house manager locked up all items during visit. Administrator agrees to retrain staff and submit training record with staff signatures to CCL by the POC due date.

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed that a basket of medication was left on the desk in the office where widely opened, and the centrally stored medicines was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2022
	Plan of Correction
1 2 3 4	The house manager locked it up during inspection. Administrator agrees to retrain staff and submit training record with staff signatures to CCL by the POC due date.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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