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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:50:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221213165120
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
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not adequately address bed bugs in the facility
Staff did not seek medical care for resident in a timely manner
Staff did not keep resident's authorized person informed about incidents
INVESTIGATION FINDINGS:
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On 12/16/2022 at 11:40 AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a 10-day complaint investigation visit in regard to the above allegations and delivered investigation findings. LPA met with house manager and informed the reason for visit.

Allegation: Staff did not adequately address bed bugs in the facility – Substantiated
The Department has investigated this allegation and per records review and interviews found that Administrator admitted that bedbug’s infection occurred in November 2022. Administrator hired pet control company to apply treatment to specific areas 3 times in November and December. The matter of bedbugs and treatments has not been addressed to other residents, resident’s representatives, and CCLD.

Continue LIC9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20221213165120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/16/2022
NARRATIVE
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Allegation: Staff did not seek medical care for resident in a timely manner – Substantiated

The Department has investigated this allegation and per records review and interviews found that Administrator was informed by staff that resident R1 had bug bites on the body on 12/8/22, however, Administrator didn't inform family member for seeking medication attention until family member visited R1 and found out on 12/13/22.


Allegation: Staff did not keep resident's authorized person informed about incidents - Substantiated
The Department has investigated this allegation and per records review and interviews found that Administrator admitted that bedbug’s infection occurred in November 2022. Administrator didn’t inform residents’ representatives and report to CCLD.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are substantiated.
Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). 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.

Based on instruction from pet control company, facility needs to be vacant for the bedbugs treatment. Administrator agrees to provided a relocation plan by today's day.

Exit interview conducted with house manager and Administrator on the phone. Appeal Rights, LIC9099D, and copy this report 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20221213165120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87405(h)(5)
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87405 Administrator - Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs
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 address bedbugs incident with responsible parties which poses a potential health, safety or personal rights risk to persons in care.
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Type B
12/23/2022
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f)Basic services shall at a minimum include:
(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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 seek medical attention for resident in a timely manner 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20221213165120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
HSC
1569.269(13)
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1569.269 Enumerated rights; severability
(13)To be fully informed, as evidenced by the resident’s written acknowledgement
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 informed incident to resident's responsible parties 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221213165120

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
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not prevent an altercation between residents
INVESTIGATION FINDINGS:
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Allegation: Staff did not prevent an altercation between residents – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that there was no witness when incident was occurred at approximately 6:00am on 11/30/22, however, the house manager still called the police, ombudsman, and informed resident R1 and R2’s case manager, representative and physician in a timely manner. The house manager stated that police has never showed up after the call, resident R2’s case manager came to facility and talked to R2. R2 has been behaving so far.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 5