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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 12/30/2024
Date Signed: 12/30/2024 02:47:17 PM

Document Has Been Signed on 12/30/2024 02:47 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
CCLD Regional Office, 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:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Jazrael Pascual, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 12/30/2024 at 1:15pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Jazrael Pascual, House Manager and explained the purpose of the visit.

While LPA L. Hall was conducting a complaint investigation 15-AS-20241221181547 on 12/30/2024, it was stated R1 had eloped from the facility. LPA toured the first level of the facility, obtained R1's physician's report (LIC602), appraisal needs and services plan, and identification and emergency information.

LPA observed the following deficiencies during the visit.
  • LPA observed during interview R1 had eloped.
  • LPA observed during record review the elopement incident that occurred on 12/152024, had not been reported.
  • LPA observed R1 did not have an current annual physician's report or appraisal needs and services plan.
  • LPA observed during record review facility did not have a permit for the alterations of the facility.
  • LPA observed plan the area called the solarium is blocked with a couch, 2 refrigerators, clothing, and other items.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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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
VISIT DATE: 12/30/2024
NARRATIVE
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Continued from LIC809.
  • LPA observed facility did not have a supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days.
  • LPA observed the facility had four (4) refrigerator/freezer and all were unsanitary.


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/30/2024 02:47 PM - It Cannot Be Edited


Created By: Laura Hall On 12/30/2024 at 01:38 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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2024
Section Cited
CCR
87705(c)(4)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs... This requirement was not met as evidence by:
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Administrator agreed to implement a plan to prevent elopement of residents and submit plan to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above in having a sufficient number of staff which posed an immediate health and safety risk to persons in care.
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Type B
01/08/2025
Section Cited
CCR87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidence by:
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Administrator agreed to submit the incident report for the incident that occurred on 12/15/2024 to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in report an elopement to CCLD, which poses a potential health and safety 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/30/2024 02:47 PM - It Cannot Be Edited


Created By: Laura Hall On 12/30/2024 at 01:48 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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87555(b)(26)

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(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of 1 week and perishable foods for a minimum of 2 days shall be maintained on the premises. This requirement was not met as evidence by:
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Administrator agreed to purchase food and submit photo of food and copy of receipts to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a minimum of 1 week perishable and 2 day non perishable foods on premises, which poses a potential health and safety risk to person in care.
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Type B
01/08/2025
Section Cited
CCR87555(21)

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(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F, and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F. They shall be kept clean... This requirement was not met as evidence by:
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Administrator agreed to have all refrigerator/freezers cleaned and submit photos to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above with having all four (4) refrigerator/freezers sanitary, which poses a potential health and safety risk for 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/30/2024 02:47 PM - It Cannot Be Edited


Created By: Laura Hall On 12/30/2024 at 01:56 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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2025
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidence by:
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Administrator agreed to remove clothing, couch and other items from solarium and submit photos to CCLD by POC date.
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Based on observation the Licensee did not comply with the section above in have solarium area blocked with 2 refrigerators, a couch, clothing and other items, which poses a potential health and safety risk to persons in care.
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Type B
01/08/2025
Section Cited
CCR87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement was not met as evidence by:
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Administrator agreed to submit permit to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having a permit for alterations in facility, which poses a potential health and safety 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/30/2024 02:47 PM - It Cannot Be Edited


Created By: Laura Hall On 12/30/2024 at 02:03 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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2025
Section Cited
CCR
87705(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually... This requirement was not met as evidence by:
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Administrator agreed to have R1 a medical assessment and reappraisal and submit copies to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having R1 an annual medical assessment and reappraisal done, which poses a potential health and safety 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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