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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 07/21/2023
Date Signed: 07/21/2023 01:57:58 PM


Document Has Been Signed on 07/21/2023 01:57 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:PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:15CENSUS: 12DATE:
07/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
02:15 PM
NARRATIVE
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On 7/21/2023 at 10:05am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an AWOL incident report received for Resident 1(R1) on 6/26/2023. LPA met with House Manager, Jezrael Pascual, explained the purpose of the visit. LPA spoke with Administrator, Victoria Puruganan, via telephone and was give approval for house manager to sign documents.

Upon arrival LPA observed front window broken with red tap holding window.

Incident report stated R1 AWOL'd on 06/23/2023. Staff 2 (S2) stated that Resident 1 (R1) normally takes a nap around 2pm, however staff went to check on R1 and noticed he was not in his room or outside. S2 stated staff checked to both corners of the street. S2 then called Administrator, 9-1-1, and hospitals. Oakland Police Department notified facility later that night he was found in Pleasanton. R1 was discharged back to the facility on 6/24/2023. S2 stated Staff 3, 4, and 5 (S3, S4, and S5) were also present during the incident. Review of R1's 602 dated 4/2/2023 indicate R1 is not able to go into the community without supervision.

S2 stated during interview that R1 AWOL'd again on 7/17/2023 and was found in Fremont. R1 was discharged on 7/18/2023. Incident report was submitted to CCLD on 7/18/2023.

Continued LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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 6


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: 07/21/2023
NARRATIVE
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Continued from LIC809.

During R1's file review LPA observed that R1 has a restricted health condition, but does not have a skilled professional caring for the restricted health condition.

LPA collected the client roster. LPA requested the following documents to be submitted to CCLD by 7/28/2023: personnel record (LIC500), physician's report (LIC602) appraisal needs and services plan, and admission agreement.

LPA observed office was different than on facility sketch. LPA toured facility with house manager and observed. LPA observed that part of the activity/entertainment room was turned into a bedroom and R2 was placed in that room. Bedroom #9 was split into two (2) rooms. The area called the solarium is blocked.

During reviewed of R2's file, LPA observed the physician's report was last conducted 9/24/2018, appraisal needs and services 9/25/2019.

LPA observed the following deficiencies:
  • R1 does not have a skilled professional to caring for his restricted health condition.
  • R2 does not have a current physician report or appraisal needs and services plan.
  • The area called the solarium is blocked with a couch, 2 refrigerators, 13 5-gallon water bottles, a small piano, clothing, and 3 walkers.
  • The facility have conducted alterations and did not obtain a permit or notify CCLD


Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 07/21/2023
NARRATIVE
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Continued from LIC809C.

The following 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. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/21/2023 01:57 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87623(b)

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87623 Indwelling Urinary Catheter (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: This requirement was not met as evidence by:
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Administrator agreed to implement a plan to assist R1 with his restricted health condidtion and submit the plan to CCLD by POC date.
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Based upon LPA's interview and record review the Licensee did not comply with the section cited above in having a skilled professional for a restricted health condition, which poses a potential health and safety risk for persons in care.
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Type B
07/28/2023
Section Cited
CCR87468.2(a)(4)

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(a) ... residents in privately operated residential care facilities... shall have all of the following personal rights: (4)... supervision... that meet their individual needs... by staff that are sufficient in numbers... This requirment was not met as evidence by:
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Administrator agreed to implement a plan to prevent AWOL's from the facility in the future and submit the plan to CCLD by POC date

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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 07/21/2023 01:57 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87705(c)(5)

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87705 (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 obtain a current medical assement and appraisal needs and services, and submit a copy to CCLD by POC date.
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Based on LPA's record review the Licensee did not comply with the section cited above in have a current medical assessment or appraisal, which poses a potential health and safety risk for persons in care.
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Type B
07/28/2023
Section Cited
CCR87307(d)(6)

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87307 (d)T he following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways... shall be kept free of obstruction. This requirement was not met as evidence by:
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Administrator agreed to remove all objects to make indoor passageway free of obstruction and submit a photo to CCLD by POC date.
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Based on LPAs observation the Licensee did not comply with the section cited above in having an indoor passageway free of obstruction.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/21/2023 01:57 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87305(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 an updated facility sketch and LIC200 to CCLD by POC date.
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Based on LPA's observation and record review the Licensee did not comply with the section cited above in obtaining a permit or notifying CCLD about the alterations, 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6