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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 08/27/2021
Date Signed: 08/27/2021 03:14:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SERENITY CARE VILLA LLCFACILITY NUMBER:
342700834
ADMINISTRATOR:JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:7274 PRITCHARD ROADTELEPHONE:
(916) 376-7778
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Linda JackLinda JackTIME COMPLETED:
04:00 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) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 08/27/2021. LPA met with Staff Linda Jack and explained the purpose of the visit. Ibifubara Jack is the Administrator and holds certificate #6046173740 that expires on 11/28/2021.

This facility is a single story building licensed to serve six (6) non-ambulatory residents at any given time. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (115) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 05/19/2020. Thermostat observed at (78) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations.

The following forms need updating and submitted to CCLD by 08/30/2021:
LIC 308 copy of administrator certificate
LIC 500 copy of liability insurance
LIC 610

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were found during today's visit. Exit interview held with Ibifubara Jack and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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