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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001208
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:54:46 AM


Document Has Been Signed on 02/23/2024 11:54 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
02/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator- Victor BurahcekTIME COMPLETED:
12:10 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
On 02/23/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct a plan of correction visit. LPA met with administrator, Victor Burachek and explained the purpose of the visit.

LPA cited on 12/19/23 due to deficiencies found during annual inspection. Administrator did not send in plan of correction that was due on 01/19/24.

LPA and Administrator discussed R1's family member was notified to not bring over the counter medications to R1's room. During today's visit this deficiency was cleared. POC letter provided

Additionally, LPA conducted a file review of R2's file and observed that R2's LIC 602 is not updated. Administrator stated that there was no appointments available. Administer plans to take R2 next week to get an updated LIC602.


LPA will recite deficiencies. There were deficiencies found during today’s inspection. Deficiencies are cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809D. If the deficiency is not corrected by the noted due date civil penalties may be assessed.

Exit interview conducted and appeal rights given.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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 02/23/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: BETHESDA
FACILITY NUMBER: 347001208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87458(c)

1
2
3
4
5
6
7
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to notify LPA Ratajczak once R2's new LIC602 is completed.
Licensee is to submit a statement of understanding that all residents in care are to obtain updated LIC602 annually.
Plan of Correction is due 03/08/2024 via fax or email to LPA Ratajczak.
8
9
10
11
12
13
14
Based on file review, the licensee did not comply with the section cited above as LPAs observed R2's most recent medical assessment on file to be dated 08/23/2005 which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2