<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:08:51 PM

Document Has Been Signed on 05/13/2025 03:08 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OPAL CARE LLCFACILITY NUMBER:
019200672
ADMINISTRATOR/
DIRECTOR:		PURUGANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:3917 OPAL STREETTELEPHONE:
(510) 420-0731
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 15CENSUS: 11DATE:
05/13/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jezrael Pascual, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/13/2025 at 1:30 pm, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael called Licensee/Administrator, Victoria Puruganan, to inform.

On 03/26/2025, the Department held a Non-Compliance Conference (NCC) meeting with the Licensee, Victoria Puruganan. The Plan of Corrections (POC) was discussed with Licensee to get the facility in compliance. The due dates were 04/09/25, 04/30/25 and an extension was granted per the Licensee's request for 05/02/25.

Deficiencies not cleared:

  • 87405(a)(b) Administrator - Qualifications and Duties $100.00 x 13 days = $1,300.00

  • 87788(h)(1)(A) Continuing Education Training Program Vendor Requirements $100.00 x 13 days = $1,300.00
  • 87458(c) Medical Assessments $100.00 x 11 days = $1,100.00

  • 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities $100.00 x 34 days = $3,400.00

Civil Penalties in the total amount of $7,100.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.


Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 05/13/2025 03:08 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/13/2025 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
Section Cited
CCR
87405(a)(b)

1
2
3
4
5
6
7
(a) All facilities shall have a qualified...The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to hire a qualified Administrator that will be present 40 hours a week by April 30, 2025.
8
9
10
11
12
13
14
Based on observation, record review and interview the licensee did not comply with the section cited above in by hiring a qualified administrator that will be present at the facility for 40 hours a week which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/30/2025
Section Cited
CCR87788(h)(1)(A)

1
2
3
4
5
6
7
87788(h)(1)(A) Continuing Education Training Program Vendor Requirements

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Training for all staff by CCLD approved vendors, including Licensee, completed by April 30, 2025:
4 Hours Training for proper eviction procedure

4 Hours training for dementia care and responding to elopements

4 Hours training for observing for changes in condition
8
9
10
11
12
13
14
Based on observation, record review and interview the licensee did not comply with the section cited above in by completing staff training with a approved CCLD approved vendor which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
4 Hours training for reporting requirements

4 Hours training for appraisals and re-appraisals

4 Hours training for records keeping
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/13/2025 03:08 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/13/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OPAL CARE LLC
FACILITY NUMBER: 019200672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
87458(c)

1
2
3
4
5
6
7
87458(c) Medical Assessments

(c) The licensee shall obtain an updated medical assessment when required by the Department

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Provide Physician's Reports for all residents, fully completed within the past 12 months, by April 30, 2025.
8
9
10
11
12
13
14
Based on observation, record review and interview the licensee did not comply with the section cited above in by not submitting updated physician's reports for all eleven (11) residents which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/09/2025
Section Cited
CCR87468.2(a)(4)

1
2
3
4
5
6
7
87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities..

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Develop a comprehensive plan for adequate staffing that addresses the ability to monitor all areas of the facility, provide for all required needs of residents, by April 9, 2025.
8
9
10
11
12
13
14
Based on observation, record review and interview the licensee did not comply with the section cited above in by not submitting a comprehensive plan for adequate staffing and to identify, document and mitigate elopements which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Develop a comprehensive plan to identify, document, and mitigate the potential for elopements, by April 9, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4