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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001208
Report Date: 12/28/2022
Date Signed: 12/28/2022 09:45:06 AM


Document Has Been Signed on 12/28/2022 09:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BETHESDAFACILITY NUMBER:
347001208
ADMINISTRATOR:VICTOR BURACHEKFACILITY TYPE:
740
ADDRESS:8312 BRAMBLE TREE WAYTELEPHONE:
(916) 723-4960
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victor Burachek- LicenseeTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 12/28/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Victor Burachek, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: four (4) bedrooms and four (4) bathrooms for residents, common area, dining room, kitchen, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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