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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 12/30/2024
Date Signed: 12/30/2024 02:43:06 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
12/21/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20241221181547
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:
12/30/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jazrael Pascual, House ManagerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility.
INVESTIGATION FINDINGS:
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On 12/30/2024 at 10:25am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegation above. LPA met with Jazrael Pascual, House Manager and explained the purpose of the visit.

During the investigation the LPA interviewed staff, obtained a copy of the personnel record (LIC500), resident roster, a copy of December calendar, R1's physician's report (LIC602), identification and emergency contact, and appraisal needs and services plan.

Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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-20241221181547
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: 12/30/2024
NARRATIVE
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Continued from LIC9099.

Based on interviews with S2 and S3 there were three (3) staff during the day. Staff noticed that R1 was missing before dinner, which is around 4pm, because R1 didn't come to eat. S2 also stated staff thought R1 was outside in the front area. S2 stated R1 goes outside into the front area without supervision. S1 stated she was not working on 12/15/2024, the day of the incident; however, S1 received a call from R1's responsible party stating R1 was missing from the facility.

Based on interviews the deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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.

*An immediate Civil Penalty of $1,000 is being assessed on today's date for a repeat violation*



Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241221181547
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2024
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff...
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Administrator agreed to implement a plan to assist with staffing and submit plan to CCLD by POC date.
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This requirement was not met as evidence by:
Based on interviews the Licensee did not comply with the section cited above in having sufficient supervision for residents, which posed an immediate health and safety risk to persons in care.
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*An immediate Civil Penalty of $1,000 is being assessed on today's date for a 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3