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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005312
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:17:47 PM

Document Has Been Signed on 11/26/2024 04:17 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/
DIRECTOR:		MERCURIO, STEPHENFACILITY TYPE:
772
ADDRESS:373 RALCAM PLACETELEPHONE:
(949) 646-2456
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Kirachan McCrory RamirezTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Program Manager (PM) Kirachan McCrory Ramirez and discussed the purpose of the inspection. Administrator (AD) Kavi Dewan was not present during the inspection.

LPA reviewed Infection Control requirements. At about 1:30PM, LPA and PM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 3-bedroom, 2-bathroom, 2-story house with an attached garage that is being used as an office. There is a back yard with a patio cover for the clients. Client Bedrooms: the 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature tested between 113 and 113.9 degrees F in the 2 client bathrooms. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the med room. Toxins: observed locked in the cleaning closet. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:30PM, LPA reviewed 5 client files and 4 staff files, interviewed 2 clients and 2 staff, inspected medications for 5 clients, and inspected client property and property logs for 5 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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Document Has Been Signed on 11/26/2024 04:17 PM - It Cannot Be Edited


Created By: Sean Haddad On 11/26/2024 at 04:03 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
, 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Guardian records and admission, S1 was not background cleared and has been working at the facility for more than 5 days, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 11/27/2024
Plan of Correction
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During the inspection, the licensee removed S1 from the facility and LPA confirmed. The licensee stated they will not be returning to the facility unless they are background cleared. POC Cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 04:17 PM - It Cannot Be Edited


Created By: Sean Haddad On 11/26/2024 at 04:03 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
, 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1562.5(d)
Other Provisions
(d) All administrators of adult residential and program directors of social rehabilitation facilities licensed on or before January 1, 1994, shall complete the training by December 31, 1994, and every two years thereafter. Newly employed administrators and program directors shall complete training within six months after commencing employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on admission, the administrator and program director have not completed the HIV/TB training, which poses a potential health risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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The licensee stated they will have the administrator and program director complete the 3 hour HIV and 1 hour TB training and will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


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: 11/26/2024
NARRATIVE
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During the inspection, LPA and PM observed the following: based on Guardian records and admission, S1 was not background cleared and has been working at the facility for more than 5 days; and based on admission, the administrator and program director have not completed the HIV/TB training.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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