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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001208
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:51:23 PM

Document Has Been Signed on 12/19/2023 12:51 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:BETHESDAFACILITY NUMBER:
347001208
ADMINISTRATOR:VICTOR BURACHEKFACILITY TYPE:
740
ADDRESS:8312 BRAMBLE TREE WAYTELEPHONE:
(916) 723-4960
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 4DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caregiver Grigori JitariTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPAs) Cheyenne Ratajczak and Cassie Yang arrived unannounced to conduct a required 1- year annual inspection utilizing the full CARE tool. LPAs met with caregiver to contacted Administrator via telephone who spoke with LPAs on speaker phone. Administrator informed LPAs that an annual inspection was conducted by LPA Williams-Lyons in August 2023. LPAs explained that due to the annual inspection being four months prior to anniversary date, it was required for another inspection closer to anniversary date. Administrator stated he is driving and will be at the facility within an hour.

During today's visit, LPA Yang and Caregiver conducted a tour of the interior of the facility. LPA Yang observed joint muscle mediation and Magnesium supplement present in R1's room. LPAs advised facility to lock and secure sharps immediately after use.

LPA Ratajczak conducted a file review of 3 resident records, and 2 staff records. It was discussed with Administrator that medical assessments need to be done annually. LPA Ratajczak observed R2s LIC602 to be dated 08/23/05. It was further discussed that staff training needs to be done annually. Along with updated CPR and first aid training's.

Water temperature observed at 119* indoor temperature at 73 degrees.

LPAs completed full care tool. Please see LIC809D

Exit interview was conducted a copy of the report and appeal rights were left at the facility.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 12:51 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 12/19/2023 at 12:24 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: BETHESDA
FACILITY NUMBER: 347001208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)
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:
Deficient Practice Statement
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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.
POC Due Date: 01/19/2024
Plan of Correction
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Licensee is to notify LPA Ratajczak once R2's new LIC 602 is completed.
Licensee is to submit a statement of understanding that all residents in care are to obtain updated LIC 602 annually.
Plan of Correction is due 01/19/2024 via fax or email to LPA Ratajczak.
Type B
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA Yang observed four bottles of medication in R1's room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Medications were collected immediately by caregiver.
Licensee will notify family members to not bring PRN medications/supplements to facility unless prescribed by the doctor with medications to be centrally stored.
Plan of Correction due to LPA Ratajczak via fax or email by 01/19/2024.
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 Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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