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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:55:51 PM


Document Has Been Signed on 12/16/2022 02:55 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 LLCFACILITY NUMBER:
019200672
ADMINISTRATOR:PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:15CENSUS: 14DATE:
12/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
03:05 PM
NARRATIVE
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On this day 12/16/22, Licensing Program Analyst (LPA) C. Lin conducted a case management visit and met with house manager and Administrator on the phone. LPA explained the purpose of the visit.

During an investigation conducted by the Department, records obtained indicated that facility did not reported incident regarding the bedbugs and treatment to CCLD in November 2022.

A deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.



Exit interview conducted with Administrator. A copy of this report and Appeal Rights was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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 12/16/2022 02:55 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: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited

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87211 Reporting Requirements
(a)Each licensee shall furnish to the licensing agency such reports...including, but not limited to, the following: (2) Occurrences, such as...which threaten the welfare, safety or health of residents....
This requirement is not met as evidenced by…
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Administrator agrees to review regulation and submit a self-certification to be in compliance in future events to CCL by the POC due date.
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Based on observation the licensee did not comply with the section cited above. Facility didn't report incident to CCL when incident occurred 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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