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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:47:17 PM

Document Has Been Signed on 12/20/2024 03:47 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/
DIRECTOR:		PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 15CENSUS: 10DATE:
12/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Jezrael Pascual, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 12/20/2024 at 2:45 PM, Licensing Program Analyst (LPA) D. Doidge conducted an unannounced Case Management visit based on information received by the agency on (the date of visit). LPA met with Jezrael Pascual, House Manager, and explained the purpose of the visit.

LPA D. Doidge tried to obtain the following documents for R1.

1. Admissions Agreement (Opal)
2. Medical Assessments
3. Appraisal Needs and Services
4. Emergency & Identification
5. Any copies of Doctor’s Orders
6. Incident Reports if any

The facility did not have any of the records available.

One citation issued..

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/20/2024 03:47 PM - It Cannot Be Edited


Created By: David Doidge On 12/20/2024 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
87755(c)

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The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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Administrator to provide copies of resident's records to LPA by POC date by email.
1. Admissions Agreement (Opal)
2. Medical Assessments
3. Appraisal Needs and Services
4. Emergency & Identification
5. Any copies of Doctor’s Orders
6. Incident Reports if any
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Based on record review, the licensee did not comply with the section cited above by not having the resident's records available at the facility for LPA to inspect during regular business hours. LPA was informed that resident’s records was moved to another facility in which resident was transferred to which poses a potential health, safety or personal rights risk to persons in 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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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