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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 07/29/2025
Date Signed: 07/29/2025 09:04:50 PM

Document Has Been Signed on 07/29/2025 09:04 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:
07/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Victoria Puruganan, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 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 07/29/2025 at 10:00 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct case management inspection as part of on-going monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPA met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael phoned Licensee/Administrator, Victoria Puruganan to inform. Victoria arrived approximately an hour later.

On 06/17/2025 LPA's L. Alexander and D. Doidge conducted a Case Management visit in which deficiencies were cited with a Plan of Correction (POC) due date of 06/24/2025. LPAs were unable to return before 10 days POC visit. Deficiencies will be re-cited.

LPA L. Alexander obtained copies of Residents (R) R1-R11 Medication Administration Records (MARs) for July 2025, Resident Registry List, Medical Assessment (LIC602-A) for R11, Emergency Disaster Plan (signed 02/27/2025) and screenshot print of building permit (filed 03/18/2024).

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:



At 10:09 am LPA observed R4 in a hospital bed without a doctor's order
At 10:09 am LPA observed unfinished wall constructions in bedrooms #9-12 including upstairs bedrooms.
At 10:14 am LPA observed unlocked medications in refrigerator located in sun porch
At 10:15 am LPA observed foods in containers, food bags/freezer bags unlabeled without dates located in refrigerators on sun porch that was expired and spoiled

LIC809-C Continued...
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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 9
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 9
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: 07/29/2025
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
26
27
28
29
30
31
32
LIC809-C Continued... (Page 2)

At 10:20am LPA observed meats in rear refrigerator not contained in proper storage and freezer was not cleaned
At 10:21 am LPA observed expired opened boxed Cherrios Cereal, salad dressing bottles, eggplants that was spoiled located in rear sunroom porch
At 10:23 am LPA observed bottle Awesome Window Clean
At 10:27 am LPA observed 1/2 bed rails on R5's bed without doctor's orders
At 10:38 am LPA observed three (3) ladders, window screens, crutches, yard shovels, hoes, lawn mower, dolly, rakes, wood, sink, cooking pot in rear backyard
At 10:39 am LPA observed laundry room door unlocked where Fabuloso Multi Cleaner, bleach, toxic chemicals were located
At 10:39 am LPA observed screens, wheelchair in rear side backyard
At 10:40 am LPA observed spoiled vegetables, expired gallons of milk, bottles of milk, unlabeled foods in refrigerator and freezers located on side back yards
At 10:48am LPA observed four (4) boxes of laminate flooring upstairs, in which laminate flooring was unwrapped laying on hallway floor
At 10:52 am LPA observed missing shower mats and no toilet paper in two (2) shared bathrooms located upstairs
At 11:02 am LPA observed Lysol Disinfectant Spray located in locked closet with dried foods
At 11:03 am LPA observed expired Velveeta Shells & Cheese, opened waffle cones and bagged brown rice
At 11:05 am LPA observed toilet paper, bag of fruits, boxes of hot dog buns, Brownie Bars located in locked closet with fans, tool boxes, lotions, sprays, antiseptic rinse

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights, LI421BG, LIC421FC, LIC421IM 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: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 03:05 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2025
Section Cited
CCR
87355(e)(3)

1
2
3
4
5
6
7
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review (b) shall prior to working...in a licensed facility: (3) Request a transfe...of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator submitted LIC9182 and US Issued ID for S3. S3 associated during visit. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above in not having S3 associated with Guardian systems which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Civil Penalty $500.00 assessed.
Type A
07/30/2025
Section Cited
CCR87555(b)(3)(26)

1
2
3
4
5
6
7
87555 General Food Service Requirements (b) The following food service requirements shall apply:(3) Between-meal nourishment or snacks shall be made available for all residents...(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to get snacks/fresh fruits/vegetables/tuna..other canned foods for residents other than carbs. Will submit photos of purchase and send a copy of receipts to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above in not having snacks, nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Immediate Civl Penalty $500.00 assessed.
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 03:34 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2025
Section Cited
CCR
87621(2)(b)

1
2
3
4
5
6
7
87621 Colostomy/Ileostomy

In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to submit an exception request with all supporting documents including but not limited signed documents by appropriately skilled professionals and submit to CCLD by POC date.
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 not having exception request for R5's ostomy bag with documents that an appropriately skilled professional is caring for ostomy bag which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
08/05/2025
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Administrator will submit photos of entire back yards cleans to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above in not having backyards clean, refrigerators/freezers clean which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Repeat Violation $250.00
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 03:50 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
87307(a)(3)(D)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to purchase toilet paper and submit receipts to CCLD by POC due dates. Send photos of having toilet paper available for residents.
8
9
10
11
12
13
14
Based on observation and interview the licensee did not comply with the section cited above in not having toilet paper in shared bathrooms for residents which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
08/05/2025
Section Cited
HSC1569.605

1
2
3
4
5
6
7
§1569.605 Liability insurance; coverage requirements

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.


This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit copy of liability insurance to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interview the licensee did not comply with the section cited above in not having liability insurance which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 04:21 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2025
Section Cited
CCR
87608(a)(3)

1
2
3
4
5
6
7
87608 Postural Supports
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit doctor's order for 1/2 rail bed and/or hospital bed for R4 and R5 to CCLD by POC due date.
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 not having doctor's orders for hospital bed and bed rails for R4 and R5 respectively which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 04:30 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2025
Section Cited
CCR
87628(a)

1
2
3
4
5
6
7
87628 Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit request for exception for R5's and R6's restricted condition - diabetes management and submit to CCLD by POC date.
8
9
10
11
12
13
14
Based on record review and interview conducted, R7 is diabetic and per dr's medication orders requires insulin injections daily at night. However, R5 and R6 is unable to check own blood sugar and administer own injections per current physician's report, which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Repeat Violation $250.00
Type A
07/30/2025
Section Cited
CCR80075(k)(1)

1
2
3
4
5
6
7
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:

(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
1
2
3
4
5
6
7
Administrator to place the insulin in a lock box and send a photo to CCLD by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on observation there was unlocked insulin located in the refrigerator which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Repeat Violation $250.00
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/29/2025 09:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/29/2025 at 04:39 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2025
Section Cited
CCR
80086(a)(c)

1
2
3
4
5
6
7
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.
1
2
3
4
5
6
7
Administrator agrees to submit a proposed plan with a timeline, updated facility sketch and copy of building permit to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in by not notifying Licensing of the renovations, providing a copy of building permit and ensuring that residents will be safe during renovation which poses an health and safety risk to persons in care.
8
9
10
11
12
13
14
Repeat Violation $250.00

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 9 of 9