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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700573
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:45:31 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20211109113648
FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IVFACILITY NUMBER:
342700573
ADMINISTRATOR:BEZDEK, SEANFACILITY TYPE:
772
ADDRESS:10821 & 10827 FAIR OAKS BLVDTELEPHONE:
(916) 903-7028
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:14CENSUS: 3DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Miriam Whyman, TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not communicate with authorized representative promptly and completely.
INVESTIGATION FINDINGS:
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On 3/8/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Miriam Whyman. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. Additionally, LPA was screened with temperature at the facility. Administrator Sean Bezdek arrived to assist

The department conducted records review and extensive interviews.
The department finds that the allegations cited above are substantiated.

Statements by R1’s family member and by facility Administrator found that on February 4, 2021, R1’s family member called the facility and spoke with the Administrator. Administrator stated that look into R1’s status and
Report continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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 7
Control Number 25-AS-20211109113648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573
VISIT DATE: 03/08/2022
NARRATIVE
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facility staff will get back to her. Administrator stated that he did not tell R1’s family member of R1’s death because he understood that they Coroner’s office would be the ones to notify family.
However, R1 had signed a release for the facility to speak with R1’s family member regarding her care and progress.
Last, CCR, Title 22 regulation 80061(f) Reporting Requirements (f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
While the Coroner’s office will notify families of a death, the Licensee is not absolved of that duty, particularly when asked how the client is doing and is known to be deceased.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Administrator. Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 25-AS-20211109113648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/22/2022
Section Cited
CCR
80061(f)
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Reporting Requirements (f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any. (LPA Noted: a,1,A is death of a client.)This requirement was not met based on statements which found the Administrator failed to notify R1’s family member of R1’s
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Licensee will submit a statementof understanding of this regulation by 3/22/22.
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 death when the family member called on 2/4/21 and approximately 8 AM.
This posed a potential violation of resident's rights.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20211109113648

FACILITY NAME:AKUA BEHAVIORAL HEALTH INC IVFACILITY NUMBER:
342700573
ADMINISTRATOR:BEZDEK, SEANFACILITY TYPE:
772
ADDRESS:10821 & 10827 FAIR OAKS BLVDTELEPHONE:
(916) 903-7028
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:14CENSUS: 3DATE:
03/08/2022
ANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Miriam WhymanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision resulted in resident's death.
Facility did not report resident's change of condition to the authorized representative.
INVESTIGATION FINDINGS:
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On 3/ 8/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Miriam Whyman. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. Additionally, LPA was screened with temperature at the facility.Admonistrator arrived to assist.

The department conducted records review and extensive interviews.
The department is unable to find and or meet the preponderance, per policy.

The department initially investigated this incident from February 9, 2021 to June 1, 2021 in response to the incident report of a suicide death which was submitted to the department. While that investigation’s findings
Report continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20211109113648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573
VISIT DATE: 03/08/2022
NARRATIVE
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were being reviewed at the regional office additional allegations were made in this complaint on November 19, 2021. The department reopened the complaint and reviewed additional information.

The documents reviewed and statements provided found that On February 4, 2021, R1 was found hanging in their bedroom closet by Mental Health Technician (staff), S1, who called 911 for immediate medical attention, while another staff, S2, who arrived from an adjacent building, performed CPR on R1 until emergency medical personnel arrived. The Coroner pronounced R1 deceased from asphyxia due to hanging.
According to the police report, the coroner stated that there was nothing suspicious about R1's suicide.

The facility provided documentation that supported staffs' statements that R1 was checked on every 30 minutes as required by Akua, up to when she was found R1 in her room deceased. While the overnight staff documented that they completed all required 30-minute checks of R1, the Akua Compliance officer acknowledged that there were some inaccuracies in the Shift report that noted that R1 had slept all night.

Though the facility has video surveillance camera’s at the facility, one of which is mounted in the hallway outside R1’s bedroom, the facility administrator denies reviewing the recording for February 3, 2021, 11:00pm to February 4, 2021 5:30am to review if R1 had left their room that night or if S3 did all room checks as they indicated. The facility’s compliance officer stated that in response to other staff reviewing the video and alleging S3 did not do complete checks at needed, the Compliance Officer looked at the video for the 5:00 am check done by S3 to R1’s room on February 4, 2021. The Compliance officer stated that they observed S1 to partially open R1’s door and see R1 in their bed.

Report continued
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 25-AS-20211109113648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573
VISIT DATE: 03/08/2022
NARRATIVE
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At the time that the allegation of video evidence was alleged to show S3 had not done checks as required, November 2021, the video was not longer available. Although the Administrator stated they believed that recordings only lasted for 72 hours, the facility’s technical support person stated that video is maintained for 48 days before the system overwrites new video over old on the hard-drive. Two people who reported that they had seen the video of the entire evening, were unable to produce a copy of the video to investigators.

S3, when interviewed, stated that while she did not receive training on how to do overnight client checks, she was able to see into R1’s room at approximately 5:00 AM on February 4, 2021 and saw what she thought was R1 in her bed. Administrator and Compliance officer stated that S3 did not complete checks as required. Overnight staff are to fully enter client rooms to see that the client is in bed and breathing. It was acknowledged that the view from R1’s bedroom door is obstructed by the closet wall making the the upper half of the bed not visible from the door.

According to therapist notes and staff statements, R1 did not display any actions or make any statements that gave staff reason for concern that R1 had suicidal tendencies or thoughts. According to a facility Suicide Risk Assessment document that R1 completed prior to her admittance, R1 denied having a history of prior suicidal attempts, self-injurious behavior or hospitalization; thus Akua assessed R1 as a "low" risk for suicide.

Lastly, it was alleged that the authorized resident was not informed of R1’s change of condition.
Report continued.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 25-AS-20211109113648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573
VISIT DATE: 03/08/2022
NARRATIVE
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Resident records and interviews found that while R1 was thought to not be totally forthcoming with therapist, R1 was showing outward signs of positively participating in activities and interactions with others. After R1’s death, it was reported that family reviewed R1’s journal which contained thoughts not shared with therapists.
It appears that facility staff shared what they observed and what was told to them by R1 to R1’s family representative.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Exit interview conducted and report copy provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7