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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 12/11/2024
Date Signed: 12/11/2024 07:50:34 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
11/13/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241113155956
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: 10DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident eloping from facility
INVESTIGATION FINDINGS:
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On 12/11/2024 at 4:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with House Manager, Jezrael Pascual, to deliver the findings of above allegation. LPA explained the purpose of the visit with Jezrael Pascual. Jezrael called Administrator, Victoria Puruganan, to inform.

During the investigation, the LPA obtained the following documents from the facility – copy of R1’s admission agreement, physician’s report, Pre-Placement Appraisal, Resident Appraisal, Appraisal Needs and Services, medication list, resident registry list, staff roster (LIC 500), MAR (October and November), Unusual Incident Report (07/18/2023, Oakland Police Department (OPD) Report #23-036660, Washington Hospital After-Visit Summary (02/03/2024) and Regional Medical Center of San Jose Patient Discharge.

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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 4
Control Number 15-AS-20241113155956
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: 12/11/2024
NARRATIVE
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LIC9099-C (Page 2)

Allegation: Staff did not provide adequate supervision resulting in resident eloping from facility
Finding: Substantiated

During the investigation, the LPA conducted interviews of facility staff (S), and witnesses (W).

On 11/18/2024 LPA interviewed W1. W1 stated that R1 arrived at Regional Medical Center of San Jose (RMC) on 11/13/2024 at around 3:00 AM. W1 stated that R1 was found in San Jose and that the Emergency Medical Services (EMS) transported R1 to the Emergency Department (RMC) for evaluation. W1 stated that R1 was disoriented and presented with an altered mental status. W1 stated that R1 was hospitalized and was receiving treatment for an infection before they would get discharged. W1 stated that they found out that Opal Care LLC (facility) have gave notice of 30-Day eviction to R1 and that they were not going to accept R1 back after being discharged. W1 stated that they spoke with the Administrator and advised that they have to accept R1 back to the facility. W1 stated that a Missing Persons Report was filed by the family and not the facility.

On 11/20/2024 LPA interviewed S2. S2 stated that on 11/12/2024 the staff did a “roll call” for dinner at around 4:15 PM to 4:30 PM. S2 stated that S2, S4, S5 and S6 noticed that R1 was not in the facility. S2 stated that S2, S4, S5 and S6 searched all the rooms, the neighborhood and S3 drove to MacArthur Bart Station to look for R1. S2 stated that on 11/17/2024, another resident, R2, was admitted to Kaiser Permanente Oakland Emergency Department (ED) after being found. S2 stated that the ED Physician called them and said that they attempted a call to the administrator at the facility but there was no answer. S2 stated that they received the call and that they called the facility to confirm if R2's was missing and staff confirmed that R2 was not at the facility.




LIC9099-C Continued
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20241113155956
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: 12/11/2024
NARRATIVE
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LIC9099-C (Page 3)

On 12/02/2024 LPA interviewed W2. W2 stated that this was the 3rd time that R1 has left the facility. W2 stated that they don’t know how R1 traveled to San Jose. W2 stated that the facility did call them to notify that R1 was missing and that they filed a Missing Person’s Report with OPD. W2 stated that they are trying to find another placement facility for R1. W2 stated that they received notice of 30-Day Eviction for R1.

On 12/02/2024 LPA interviewed S1. S1 stated that R1 was at the facility at around 4:00 PM, but the staff were calling R1 for dinner at 5:00 PM and that is when the staff discovered that R1 was missing from the facility. S1 stated that two (2) groups went out to search for R1. Which was S3 that drove to MacArthur Bart Station to look for R1. S1 stated that R1 “knows what he’s doing”. S1 stated that R1 goes out, then the staff will call the police, call the bus line and the family was informed.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20241113155956
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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2025
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 agreed to install an alarm at outside front gate and will send a photo/video to CCLD. Also, LIC 500 with night shift staff scheduled. In addition, Administrator will send R1's updated physician's report and Appraisal, Needs and Services to CCLD by POC date.
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Based on observation, interviews and record review, the licensee did not comply with the section cited above in by not performing re-evaluations of R1 who was diagnosed with dementia on 02/03/24 and later AWOLd a total of 3 times in which this last AWOL R1 traveled over 50+ miles and found disoriented and confused by EMS which posed a potential health and safety risk to persons in care.
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Immediate Civil Penalty of $1,000 is being assessed today for repeat violation.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4