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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700573
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:47:39 PM

Document Has Been Signed on 03/08/2022 03:47 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Miriam WhymanTIME COMPLETED:
04:00 PM
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On 3/8/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted case management visit for deficiencies found during the investigation of R1’s death. 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 arrived to assist.

81087 BUILDINGS AND GROUNDS (l) The licensee shall ensure that items which could pose a danger if readily available to clients, … are stored where inaccessible to clients. This requirement was not met based on statements by S1 That a hair straightener was found with R1 instead of being secured in the staff office. This posed an immediate risk to R1.

S1 described that found in the closet with R1 at the time of their death were a black standing lamp, a table lamp (the cord of which was used in the suicide) and hair straightener with its cord wrapped around the closet hanger bar also. S1 stated that the hair straightener should not have been left in R1’s possession rather it should have been locked in the staff office. At the time of R1’s suicide, table lamps and fans with cords were allowable. The facility has since removed fans and purchased cordless lamps.

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
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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81078(a) RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met based on statements by S3, the compliance officer and administrator that S3 did not perform overnight checks for R1 in a manner outlined in facility policy. S3 at times left doors open and at others left them closed. S3 did not fully enter client’s rooms in order to visually verify client health and safety.

81065(a) Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs…This requirement was not met based on records and interviews that showed that S3 was not trained to competently perform overnight checks on clients in care. This posed a potential risk to residents.
Plan of Supervision Documentation Form provided to the departments showed only that as of 1/26/21, S3’s training was only documented for 3 hours of training for Basic knowledge of mental disorders, counseling skills and crisis management. Client and staff safety were not documented as having been completed. S3 herself could not recall topics on which se was trained when asked by the investigator.



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
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
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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
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Document Has Been Signed on 03/08/2022 03:47 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 03/08/2022 at 01:21 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
, 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 A
03/08/2022
Section Cited
CCR
81087(l)

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BUILDINGS AND GROUNDS (l) The licensee shall ensure that items which could pose a danger if readily available to clients, … are stored where inaccessible to clients. This requirement was not met based on statements by S1 That a hair straightener was found with R1 instead of being secured in the staff office. This posed an immediate risk to R1.
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Licensee will submit a plan with tracking sheets for the process of clients receiving and returning items known to be potentially harmful.
Plan to be submitted by POC date of 3/8/22.
Request Denied
Type B
03/22/2022
Section Cited
CCR
81078(a)

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RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met based on statements that S3 did not perform overnight checks for R1 in a manner outlined in facility policy.This posed a potential risk to clients
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Licensee will submit the facility's completed training regarding monitoring of clients in care along with proof of training by the POC date of 3/22/22.
Request Denied
Type B
03/22/2022
Section Cited
CCR81065(a)

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Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs…This requirement was not met based on records and interviews that showed that S3 was not trained to competently perform overnight checks on clients in care. This posed a potential risk to residents.
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Licensee will submit a statement of understanding for this requirement to CCL by the POC date of 3/22/21.

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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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