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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 06/17/2025
Date Signed: 06/17/2025 07:01:18 PM

Document Has Been Signed on 06/17/2025 07:01 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: 10DATE:
06/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Victoria Puruganan, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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On 06/17/2025 at 3:30 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Case Management inspection as part of monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPAs met with Licensee/Administrator, Victoria Puruganan, and explained the purpose of the visit.

LPAs received and reviewed updated medical assessments for 5 (five) residents (R). During the review, LPAs observed R1 tested positive with Tuberculosis, and is currently taking a course of antibiotics for 4 months. Licensee did not have confirmation from R1's primary care physician if they were contagious or not. LPAs observed that R2's physician's report indicated that they can not administer their own insulin nor check their own blood glucose. LPAs observed that R4 had a recent Emergency Room visit of 06/07/2025 in which the After Visit Summary indicated that R4 was seen for a fall. During interview with S1, S1 stated that R4 had eloped and that the hospital called. S1 stated that they had notified CCLD but they did not have a copy of the Incident Report (LIC624). LPAs observed that R5 is diabetic on insulin and also has a ostomy bag. S1 stated that there is a nurse from Kaiser that comes to monitor R5 for the osotmy bag but S1 did not have care plan to address R5's insulin use for diabetes and ostomy.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/17/2025
NARRATIVE
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LPAs obtained copies of medical assessments for R1-R5, MAR for R3, Admission Agreement and Emergency Identification Form for R5.

Civil penalties were assessed today of $500.00 for repeat violations.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/17/2025 07:01 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 06/17/2025 at 05:17 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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2025
Section Cited
CCR
87468.2(a)(4)

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To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...

This requirement was not met as evidence by:
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By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation.
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Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.
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Civil penalty assessed $250.00 for repeat.
Type B
06/24/2025
Section Cited
CCR87211(a)(2)

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(2) Occurrences...which threaten the welfare, safety or health of residents,...shall be reported within 24 hours...

This requirement was not met as evidence by:
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By POC due date, Licensee will submit an Incident Report (LIC 624) for R4's elopement on 06/07/25.
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Based on interview and record review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs R4's elopement which posed a potential health, safety or personal rights risk to persons in care.
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Civil penalty assessed $250.00 for repeat.
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: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2025 07:01 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 06/17/2025 at 05:30 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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2025
Section Cited
CCR
87621(a)(2)

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87621 Colostomy/Ileostomy
(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances
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Administrator agreed to submit documentation care plan for R5's ostomy provided by an appropriately skilled professional by POC due date.
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Based on interview, and record review the licensee did not comply with the section cited above by not having appropriate documentation and care plan on file for R5's ostomy bag which poses a potential health and safety risk to persons in care.
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Type B
06/24/2025
Section Cited
CCR87629(a)

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(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.
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Administrator agreed to submit an exception request, appriasal needs and services and doctor's orders for R5's diabetes and insulin injection by POC due date.
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Based on interview, and record review the licensee did not comply with the section cited above by not having on file for R5 if the injections are administered by an appropriately skilled professional which poses a potential health and safety risk to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/17/2025 07:01 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 06/17/2025 at 05:40 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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2025
Section Cited
CCR
87455(c)(1)

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87455 Acceptance and Retention Limitations

(c) No resident shall be accepted or retained if any of the following apply:

(1) The resident has active communicable tuberculosis.
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Administrator agreed to submit written doctor's documentation indicating if R1 is non-contagious. If R1 is contagious Administrator will update care plan and submit an exception request for R1 by POC due date to CCLD.
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Based on interview, record review the licensee did not comply with the section cited above by not having written doctor's order indicating if R1 has active TB which poses a potential health and safety risk to persons in care.
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Type B
06/24/2025
Section Cited
CCR87465(a)(6)

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87465 Incidental Medical and Dental Care
(6) When requested by... the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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Administrator agreed to submit prescription doctor's orders for R1-R5 including but not limited to diabetes management. Administrator will conduct an In-Service training with all staff with an skilled professional from an licensed health agency.
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Based on interview and record review the licensee did not comply with the section cited above by not having a record (MAR) for R1-R5 on file which poses a potential health and safety risk to persons in care.
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Administrator will submit sign-in sheet and a copy of training synopsis to CCLD by POC due date.
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: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
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