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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005313
Report Date: 11/07/2025
Date Signed: 11/07/2025 05:36:42 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
10/13/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251013102844
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IIFACILITY NUMBER:
306005313
ADMINISTRATOR:PIYUSH SALUJAFACILITY TYPE:
772
ADDRESS:324 UNIVERSITY DRIVETELEPHONE:
(949) 873-5095
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 4DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Kavi DewanTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Staff did not provide appropriate therapy services for a client
Staff behavior poses as a risk to the clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff did not provide appropriate therapy services for a client and staff behavior poses as a risk to the clients. During the investigation, LPA conducted interviews with clients in care and staff. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff did not provide appropriate therapy services for a client, it was reported a client did not receive individual therapy for almost two weeks. LPA interviews with four out of five clients stated they receive individual therapy sessions and have not missed a session because a therapist was not available. The remaining client stated client 5 (C5) missed over a week of individual sessions because their therapist was away on jury duty.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
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 8
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
10/13/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251013102844

FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IIFACILITY NUMBER:
306005313
ADMINISTRATOR:PIYUSH SALUJAFACILITY TYPE:
772
ADDRESS:324 UNIVERSITY DRIVETELEPHONE:
(949) 873-5095
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Kavi DewanTIME COMPLETED:
05:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff exposed a client to harmful material
INVESTIGATION FINDINGS:
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5
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7
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9
10
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12
13
Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize 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 staff exposed a client to harmful material. During the investigation, LPA conducted interviews with clients in care and staff.

The investigation determined as follows: Regarding the allegation staff exposed a client to harmful material, it was reported staff showed Client 5 (C5) a video of Charlie Kirk being shot. LPA interviews with four out of five clients stated they have never been shown inappropriate materials by staff. The remaining client stated C5 was shown a video of Charlie Kirk being shot during the evening they were admitted to the facility. One out of nine staff denies showing C5 any inappropriate videos. The remaining eight staff did not add anything relevant to this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20251013102844
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 II
FACILITY NUMBER: 306005313
VISIT DATE: 11/07/2025
NARRATIVE
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Based on client interviews and staff interview, the allegations of staff exposed a client to harmful material is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

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

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 22-AS-20251013102844
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 II
FACILITY NUMBER: 306005313
VISIT DATE: 11/07/2025
NARRATIVE
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 Interviews with two out of nine staff stated C5’s primary therapist was not available on September 24 and 25, 2025 due to being away on jury duty. The remaining seven staff did not add anything relevant to the allegation. LPA record review revealed that C5 was admitted to the facility on September 10, 2025 and discharged on September 30, 2025. C5 saw a therapist five times on the following dates: 09/12/2025, 09/13/2025, 09/20/2025, 09/27/2025, and 09/30/2025. The facility’s program plan under Activities and Services states “Counseling and case management individual sessions 2x/week (Clinical Staff).”

Regarding the allegation staff behavior poses a risk to the clients, it was reported that a staff member spoke about drinking hand sanitizer to get drunk with clients. LPA interviews with four out of five clients stated they have not been told anything inappropriate by staff. The remaining client stated a staff member discussed drinking hand sanitizer to get drunk during a budgeting workshop with other clients who have substance abuse issues. One out of nine staff stated they recall discussing drinking hand sanitizer to get drunk during a group session with clients but cannot recall the context around that statement nor if it was an appropriate conversation to have with clients. The remaining eight staff did not add anything relevant to the allegation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6), are 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: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 22-AS-20251013102844
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 II
FACILITY NUMBER: 306005313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
80022(k)
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80022(k) Plan of Operation
The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

The requirement is not met as evidenced by:
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Licensee stated plan of operation wil be adjusted in order identify appropriate limits for therapy sessions. Licensee to send copy of updated plan for LPA to review.
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The facility did not provide C5 two individual theraphy sessions per week as indicated in their plan of operation which poses a potential health and safety risk to persons in care.
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Type B
11/21/2025
Section Cited
CCR
81065(a)
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81065(a) Personnel Requirements
Facility personnel shall be competent to provide the services necessary to meet individual client needs...

The requirement is not met as evidenced by:
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Licensee stated in-service training will be conducted with all staff to discussed what appropriate convesations may be had with clients. Licensee to send copy of in-service training with staff present and topics covered.
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Staff had inappropriate conversations with clients during a group session which poses a potential health and safety 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: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8