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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005313
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:31:40 PM

Document Has Been Signed on 10/06/2023 02:31 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 IIFACILITY NUMBER:
306005313
ADMINISTRATOR:MERCURIO, STEPHENFACILITY TYPE:
772
ADDRESS:324 UNIVERSITY DRIVETELEPHONE:
(949) 873-5095
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jamal Hasankhil
Peter Hilen		TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Staff Jamal Hasankhil and explained the purpose of the inspection. Chief Commercial Officer (CCO) Peter Hilen arrived at 1:00 p.m. During the inspection LPA and Staff Hasankhil conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with three client bedrooms, and two bathrooms. There is a therapy room and staff office detached from the main house. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The courtyard has a shaded sitting area. LPA observed one client present at the facility in the process of being admitted. Per staff, all other clients were away at the gym. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 118.4 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps, all and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. The medication cabinet was observed to be locked in the staff office. LPA reviewed five client files and two staff files. Clients were not present to be interviewed. LPA interviewed staff present.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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