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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005312
Report Date: 09/09/2025
Date Signed: 09/09/2025 12:06:20 PM

Document Has Been Signed on 09/09/2025 12:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IFACILITY NUMBER:
306005312
ADMINISTRATOR/
DIRECTOR:		PIYUSH SALUJAFACILITY TYPE:
772
ADDRESS:373 RALCAM PLACETELEPHONE:
(949) 646-2456
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 0DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kavi DewanTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA attempted to enter the facility but it was locked. Doorbell was not in operation. LPA observed screen cover on the second floor removed from the window. LPA reached out to the Compliant Manager (CM) Andrew Walker and explained the reason for the visit. CM confirmed no clients are in care and explained to LPA he would contact the Licensee. LPA received the call from the Licensee Kavi Dewan and confirmed he would arrive to facilitate inspection. Facility is licensed for 6 ambulatory clients. LPA observed facility has no clients in care. Licensee provided updated liability insurance that expires on 04/21/2026.

LPA along with Licensee toured the facility at 9:40 AM. LPA toured the physical plant and reviewed facility documentation. The two story home consists of 3 client bedrooms, living room, dining room, and kitchen as well as 2 bathrooms on the first floor and a medication room on the second floor. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Five out of six client areas are missing reading lamps. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured at 140.5 degrees F. Common areas were clean and clear of hazards. LPA toured the kitchen. Currently, there is no perishable or non-perishable food supplies as there are no clients in care. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans. Outside grounds were toured. Walkways around the home were clear of hazards There is no first aid kit on the premises. There are no security bars on the premises. There is shaded outdoor seating for clients.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST 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.

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 09/09/2025 12:06 PM - It Cannot Be Edited


Created By: Fred Arias On 09/09/2025 at 11:08 AM
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: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(a)
Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, facility has an inoperable door bell and no screen cover on the second floor window which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee stated screen cover will be replaced and door bell battery will be charged. Licensee will provide photos and or videos of the repair by POC due date to LPA.
Type B
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, water temperature measured at 140.5 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee stated water will adjusted to meet regulation requirements. Licensee will provide video proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


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
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
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LPA did not review staff files or clients files as there are no clients in care and there is no staff working at the facility. Medications are normally stored in the medication room when clients are present.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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