<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700573
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:00:03 PM

Document Has Been Signed on 02/22/2024 03:00 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 11DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Miriam Whyman, Compliance ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 2/22/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are seven (7) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on cite. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8 due to hot water temperature being measured at 86 degrees F. Deficiency is listed on 809-D.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/22/2024 03:00 PM - It Cannot Be Edited


Created By: Michael Hood On 02/22/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AKUA BEHAVIORAL HEALTH INC IV
FACILITY NUMBER: 342700573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the facility did not ensure that hot water was maintained not less than 105 degrees F and not more than 120 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Facility will ensure that water temperatures are controlled not less than 105 degrees F and not more than 120 degrees F. LPA will conduct a future visit to check the temperature of the hot water.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2