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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005312
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:52:08 PM

Document Has Been Signed on 09/27/2022 01:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IFACILITY NUMBER:
306005312
ADMINISTRATOR:MERCURIO, STEPHENFACILITY TYPE:
772
ADDRESS:373 RALCAM PLACETELEPHONE:
(949) 646-2456
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Emily MajanoTIME COMPLETED:
02:10 PM
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On 09/27/2022 at 12:19pm, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Akua Behavioral Health Inc I. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 12:24pm, LPA Cho was greeted and allowed entry by Clinical Technician (CT) Lyn Nguyen after completing the Coronavirus 2019 (COVID-19) screening procedure. Program Director (PD) Emily Majano arrived at the facility at 12:36pm. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility is licensed for six ambulatory clients, and there are five clients present.

At 12:41pm, LPA Cho conducted a tour of the physical plant along with CT Lyn Nguyen. The two story home consists of three client bedrooms and two client bathrooms. There is a tech office on the second floor. The facility also has a living room, dining area, kitchen, tech office, and laundry/therapy room. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in both bathrooms. LPA Cho tested the hot water temperature in the client bathrooms and the temperature measured at 118.4 degrees Fahrenheit in the Bathroom #1 and 115.5 degrees Fahrenheit in Bathroom #2.

LPA Cho inspected the kitchen along with CT Nguyen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and serviced on 08/2022. The smoke/carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC I
FACILITY NUMBER: 306005312
VISIT DATE: 09/27/2022
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LPA Cho toured the outside grounds with CT Nguyen. There were no bodies of water present. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards. There were no security bars or weapons on the premises.

Facility has back-up emergency food but no water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. LPA discussed the Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, residential care facilities for the elderly, and social rehabilitation facilities with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides a laptop and desktop when needed.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Program Director Emily Majano, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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