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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:31:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/05/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240405092549
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: 13DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff do not provide adequate supervision resulting in residents wandering away from facility.
Staff does not ensure facility is free of pests resulting in residents being bit.
.
INVESTIGATION FINDINGS:
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On 8/14/24 at 10:30 a.m., Licensing Program Analyst (LPAs) Greg Clark and David Doidge arrived unannounced to deliver findings in regard to the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit.

Allegation: Staff do not provide adequate supervision resulting in residents wandering away from facility.

LPAs interviewed S1. S1 stated that there is still no set schedule for staff to cover the afternoons and overnights. This results in some residents wandering away from the facility and sustaining falls resulting in injuries. This allegation is substantiated.

***report continues on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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 3
Control Number 15-AS-20240405092549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/14/2024
NARRATIVE
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***report continues from LIC9099***

Allegation: Staff does not ensure facility is free of pests resulting in residents being bit

The facility has entered into an agreement on 5/01/24 with Orkin for a monthly pest control treatment for the entire facility. LPA’s reviewed the agreement and that Orkin will be monitoring the facility for roached, ants, rate and mice. LPAs also reviewed a report from Orkin dated 4/18/24 for the bed bug treatment. The report states that facility is now clear of bedbugs and is monitored by Orkin monthly. This allegation is substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.CCLD1515.



Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240405092549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...-This requirement is not met as evidenced by:
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Administrator to hire one additional daytime staff, and one awake night staff. Administrator will submit copy of LIC500 Personnel Report to CCL by 8/21/24.
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Based on records review and interview, the licensee did not comply with the section above for not having sufficient staff which poses a potential safety and personal rights risks to persons in care.
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Type B
08/14/2024
Section Cited
CCR
87303(a)
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87303 (a) The facility shall be clean, safe, sanitary... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents...
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Deficiency cleared prior to visit.
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This requirement was not met as evidenced by: Based on staff, resident, and reporting party interviews, facility failed to prevent bed bugs which poses a potential personal rights of residents 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3