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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005312
Report Date: 09/09/2025
Date Signed: 09/09/2025 03:26:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20250902135634
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IFACILITY NUMBER:
306005312
ADMINISTRATOR:PIYUSH SALUJAFACILITY TYPE:
772
ADDRESS:373 RALCAM PLACETELEPHONE:
(949) 646-2456
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 0DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kavi DewanTIME COMPLETED:
03:41 PM
ALLEGATION(S):
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Facility is not following the plan of operation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint inspection to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility is not following the plan of operation. During the investigation, LPA conducted interviews with staff. LPA reviewed client records obtained and the facility plan of operation.

The investigation determined as follows: regarding the allegation facility is not following the plan of operation, it was reported client 1 (C1)'s record contained a written summary that did not include documented evidence that it was prepared by staff and client. C1's records revealed C1 was discharged on May 8, 2025. C1's discharge summary did not have C1's signature recorded and instead had the staff's signature on both the client line and staff line. Interviews with one out of two staff stated on the day C1 was discharged, C1 was picked up by another provider one hour prior to the scheduled discharge time.
Continued on LIC9099-C dated 09/09/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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 3
Control Number 22-AS-20250902135634
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC I
FACILITY NUMBER: 306005312
VISIT DATE: 09/09/2025
NARRATIVE
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Staff added C1 did not want to wait to review discharge summary with staff. C1 departed the facility without signing the discharge summary. LPA interview with the remaining staff did not add relevant information regarding C1 and the discharge summary.

LPA reviewed the facility's plan of operation and under Client File it states "All documents contained in the client file are written legibly in ink or typewritten, all entries shall be signed and dated, and all significant information pertaining to a client is included in the client file."

Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22,Division 6, Chapter 8), is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250902135634
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AKUA BEHAVIORAL HEALTH INC I
FACILITY NUMBER: 306005312
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
81022(j)
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Plan of Operation 81022(j) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so.

This requirement is not met as evidenced by:
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Licensee stated an additional text box will be added to the discharge summary stating reason for no client signature if necessary. In addition an in-service training will be performed. Licensee to provide proof to LPA by POC due date
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Based on LPA record review and interviews, the facility did not follow their Plan of Operation in completing C1's discharge summary which poses a potential health, safety, or personal rights 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3