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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005313
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:55:36 PM

Document Has Been Signed on 12/13/2022 01:55 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
12/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Kayla Nozaki, Program DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced case management visit today. LPA met with Kayla Nozaki, Program Director and explained the nature of the visit. This is to follow up on an incident report that was self reported on October 25, 2022 regarding C1 incident on October 24, 2022.

Per information collected at the facility all clients at the facility observed C1 sharpen a broken fork on the cement and indicate that C1 was going to harm C2 while they slept. Facility staff immediately separated clients due to them being upset. Staff became proactive on de-escalating the situation and called OC Sheriff to the scene. OC Sheriff visited the facility and based on the information was told CAT team advised them that it was not necessary to come out to do a visit. C1 was placed under heavy watch and was transferred to one of the other facilities for the facility. C1 remained at the new facility and was placed on 15 minute checks for safety until further notice. Facility clinician was called and met with clients and staff at the facility for debriefing, Staff clinician made sure that all clients felt safe and no adverse reactions came from incident. No adverse reactions were noted with the clients and with incident in question. Facility continues to work with clients as required and continues to be proactive on addressing any issue if they arise.

LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of the LIC809 and LIC811 was provided and left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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