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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200672
Report Date: 09/24/2025
Date Signed: 10/08/2025 02:55:50 PM

Document Has Been Signed on 10/08/2025 02:55 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
OAKLAND ASC, 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: 9DATE:
09/24/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:01 PM
MET WITH:Licensee/Administrator Victoria Puruganan TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 09/24/2025 at 4:001 PM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to open a 10-day initial visit for complaint number 15-AS-20250917130441. LPAs met with Licensee/Administrator Victoria Puruganan and explained the reason for the visit.

During the complaint investigation, LPAs noted and cited for the following deficiencies:

  • At 12:45PM, LPAs observed a resident (R1) in a room that is not fire cleared. LPAs evaluated the resident and came to the conclusion that the resident is bedridden.
  • At 1:00PM, LPAs reviewed R1's file. The Appraisal Needs And Services Plan (ANS) had not been updated March 2023 while needs have clearly changed.
  • At 1:15 PM, LPAs observed in the closet of bedroom 5 a blanket that had been soiled with urine, emitting a urine smell throughout the second floor of the facility.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: David Doidge
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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Document Has Been Signed on 10/08/2025 02:55 PM - It Cannot Be Edited


Created By: David Doidge On 09/24/2025 at 05:12 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: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2025
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance All facilities shall maintain a fire clearance…Prior to accepting or retaining any of the following types of persons…State Fire Marshal.
(2) Bedridden persons
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By POC date, Licensee will move resident out of current room, and into a cleared room. Licensee will submit photos to LPA.
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Based on observation, the licensee did not comply with the section cited above by having a bedridden resident in a non-cleared room.
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An Immediate and repeat Civil penalty of $1000 is hereby assessed.
Type B
10/01/2025
Section Cited
CCR87463(b)

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87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's ...mental, cognitive...condition, including those required to be documented as specified in Section 87466, Observation of the Resident.
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By POC date, Licensee will complete a reappraisal for R1 and submit a copy to LPA.
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Based on record review, the licensee did not comply with the section cited above by not performing a reappraisal since March 2023.
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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:
David Doidge
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/08/2025 02:55 PM - It Cannot Be Edited


Created By: David Doidge On 09/24/2025 at 05:20 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: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean...sanitary...at all times. Maintenance shall include provision of maintenance services...residents, employees and visitors.
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POC clear during visit.
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Based on observation, the licensee did not comply with the section cited above by not removing soiled linens in bedroom.
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An Immediate Civil penalty of $250 is hereby assessed.

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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:
David Doidge
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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