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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005313
Report Date: 08/12/2024
Date Signed: 08/12/2024 03:27:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/07/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240807095634
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IIFACILITY NUMBER:
306005313
ADMINISTRATOR:MERCURIO, STEPHENFACILITY TYPE:
772
ADDRESS:324 UNIVERSITY DRIVETELEPHONE:
(949) 873-5095
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 4DATE:
08/12/2024
UNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Piyush SalujaTIME COMPLETED:
03:42 PM
ALLEGATION(S):
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Facility is not following its plan of operation
Facility staff are not qualified
Facility staff are not adequately trained
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Clinical Director (CD) Piyush Saluja, discussed the purpose of the inspection, and explained the allegations.
The investigation into the allegations that the facility is not following its plan of operation, facility staff are not qualified, and facility staff are not adequately trained revealed the following: During the course of the investigation, LPA inspected the facility, interviewed CD, and obtained and reviewed copies of the resident roster, staff roster, the facility’s plan of operation, the Biopsychosocial Assessment for Client #1 (C1), Client #2 (C2), and Client #3 (C3), Treatment Plan documentation for C1 and C3, Discharge Summary and Aftercare Plan/Discharge Instruction Form for Client #4 (C4) and Client #5 (C5), Plan of Supervision Records, and Staff Training Records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
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 4
Control Number 22-AS-20240807095634
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 306005313
VISIT DATE: 08/12/2024
NARRATIVE
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Regarding the allegation that the facility is not following its plan of operation: it was alleged that the written assessment for C1, C2, and C3 did not include documented evidence that their meal planning was assessed, that the facility was not conducting ongoing review of progress towards reaching established goals with regards to C1 and C3, that the treatment/rehabilitation plan was not completed by staff for C1 and C3, and that the discharge summary for C4 and C5 did not contain documented evidence of goals accomplished and referral for follow-up plans. LPA reviewed the facility’s plan of operation which corroborated that the plan of operation required that all these steps be completed. LPA interviewed CD who admitted the allegation and stated that the facility has updated their processes and conducted training to address these issues moving forward. LPA reviewed the Biopsychosocial Assessments and for C1, C2, and C3 and Treatment Plan documentation for C1 and C3 which corroborated the allegation. LPA reviewed C4’s and C5’s Discharge Summary and Aftercare Plan/Discharge Instruction Form which corroborated the allegation.
Regarding the allegation that facility staff are not qualified: it was alleged that two staff files did not contain documented evidence that these staff had one year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities or a documented plan of supervision. LPA interviewed CD who admitted the allegation and stated that these two staff had not obtained the required experience and did not have proper plans of supervision, but that the facility has placed these staff on plans of supervision moving forward. LPA reviewed Staff Plan of Supervision Records which corroborate that these two staff did not have the required experience when they started their position or a plan of supervision, but that the facility has corrected the issue moving forward.
Regarding the allegation that facility staff are not adequately trained: it was alleged that the staff preparing the admission assessments not received training in the development of these documents and that five staff did not have documented evidence of 20 hours of annual training. LPA interviewed CD who admitted the allegation and stated that the document preparation training had been done but was not documented and that five staff had not completed the 20 hours of annual training in 2023, but that all these issues have been resolved moving forward. LPA reviewed Staff Training Records which corroborated this allegation.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. 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: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240807095634
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 306005313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
81022(j)
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81022 Plan of Operation (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 was not met as evidenced by:
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Licensee stated they have updated their processes and forms to to ensure client files contain all required information and have conducted staff training on completing the new processes and forms. Licensee stated they will submit proof to LPA by POC due date..
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Based on admission and documents, the licensee was not following its plan of operation when it did not properly complete the client files for 5 clients, which poses a potential health risk to persons in care.
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Type B
09/09/2024
Section Cited
CCR
81065(n)
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81065 Personnel Requirements (n) All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations… This requirement was not met as evidenced by:
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Licensee stated they have placed these two staff on a plan of supervision and will submit proof to LPA by POC due date.
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Based on admission and documents, the licensee did not ensure two staff had the required experience or a plan of supervision before providing care to clients, which poses a potential health 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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240807095634
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 306005313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
81065(r)
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81065 Personnel Requirements (r) All direct care staff shall receive a minimum of 20-clock-hours of continuing education per year... This requirement was not met as evidenced by:
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Licensee stated they have created a plan to ensure all staff have the required training and will submit proof to LPA by POC due date.
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Based on admission and documents, the licensee did not ensure 5 staff had completed 20 hours of annual training, which poses a potential health 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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4