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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200672
Report Date: 04/02/2025
Date Signed: 04/02/2025 05:54:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/24/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250324113724
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:
04/02/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff do not accord dignity to resident in care.
Licensee leaves resident(s) unsupervised while in care.
Staff are not seeking medical attention for resident in care as necessary.
INVESTIGATION FINDINGS:
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On 04/02/2025 at 09:30 am, Licensing Program Analysts (LPAs), D. Doidge and L. Fontanilla arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. The Administrator was informed about the visit.

During the investigation the LPAs interviewed staff and resident 1 (R1) and obtained copies of R1's physician's report (LIC602), identification and emergency contact, and appraisal needs and services plan.

Allegation: Staff do not accord dignity to resident in care
Findings: S1 had taken pictures of R1's soiled underwear and bedsheet and texted them to R1's friend with R1 included in text thread without R1's permission.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/24/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250324113724

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:
04/02/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jezrael Pascual, House ManagerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff do not ensure that resident's toileting needs are being met while in care.
Staff do not ensure that resident's hygiene needs are being met while in care.
Staff do not ensure that resident is provided with clean bedding while in care.
Staff do not safeguard resident's personal possessions while in care.
Staff member harrasses resident in care.
INVESTIGATION FINDINGS:
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On 04/02/2025 at 09:30 am, Licensing Program Analysts (LPAs), D. Doidge and L. Fontanilla arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. The Administrator was informed about the visit.

During the investigation the LPAs interviewed staff, obtained a copies of R1's physician's report (LIC602), identification and emergency contact, and appraisal needs and services plan.

Allegation: Staff do not ensure that resident's toileting needs are being met while in care.
Findings: Per Physician's report and interviews, R1 does not need assistance in toileting; is able to use toilet on own.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20250324113724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672
VISIT DATE: 04/02/2025
NARRATIVE
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Continued from LIC9099

Allegation: Staff do not ensure that resident's hygiene needs are being met while in care.
Findings: Per Physician's report and interviews, R1 is able to bathe self. R1 has preference to frequency of taking showers, and is able to take care of self.

Allegation: Staff do not ensure that resident is provided with clean bedding while in care.
Findings: Per interviews with resident and staff, bed are changed at least once a week, and more frequently as needed. Beds were observed by LPA to be clean and good repair. Facility has more than adequate linens for all beds.

Allegation: Staff do not safeguard resident's personal possessions while in care.
Findings: Facility maintains Client/Resident Personal Property and Valuables, LIC 621. R1 has reported missing an ATM card, however R1 admitted to placing ATM card in a book and not being able to remember which book it was placed in. R1 reported missing noise canceling headphones. LIC621 has headphones, but house manager mentioned that headphones was written by mistake, package that arrived had ear buds. Staff have not seen R1 with noise canceling headphones. R1 reported missing an Iphone. Staff found Iphone in R1's bed and was handed to R1 during visit.

Allegation: Staff member harasses resident in care.
Findings: During the visit, LPAs interviewed 3 residents. There was no disclosure of harassment made by staff against any resident. Resident denied harassment by staff.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

No deficiencies were issued.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20250324113724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672
VISIT DATE: 04/02/2025
NARRATIVE
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Continued from LIC9099

Allegation: Licensee leaves resident(s) unsupervised while in care.
Findings: Based on interview conducted with staff, when Licensee is on site, Licensee will monitor residents in the security cameras located in the office but will not interact with residents directly.

Allegation: Staff are not seeking medical attention for resident in care as necessary.
Findings: Based on interviews and record reviews conducted, R1 was admitted to the facility on January 12, 2025. LPAs were informed that R1 has not had any visit with a doctor because R1 does not have a primary doctor assigned yet. S1 states there is a medication that needs refill but has not been filled yet.

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.
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 was conducted. A copy of the appeal rights and , and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250324113724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
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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This deficiency has been discussed in the NCC conducted on 03/226/2025.Hire a qualified Administrator that will be present 40 hours a week, April 30, 2025
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Based on interview conducted with staff, when Licensee is on site, Licensee will monitor residents in the security cameras located in the office but will not interact with residents directly.
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Type B
04/09/2025
Section Cited
CCR
87468.1(a)(1)
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(a) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights. (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Have staff review Personal Rights and provide a self certifying letter to LPA by POC date.
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This requirement was not met as evidence by:
S1 had taken pictures of R1's soiled underwear and bedsheet and texted them to R1's friend with R1 included in text thread without R1's permission.
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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: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250324113724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2025
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical...care and provide...obtaining such care, by compliance with the following:The licensee shall arrange...for medical...care appropriate to the conditions and needs of residents.
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Assist R1 with contacting Kaiser and set up PCP. Email LPA with PCP information.
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R1 has not had any visit with a doctor because R1 does not have a primary doctor assigned yet. S1 states there is a medication that needs refill but has not been filled yet.
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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: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6