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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:53:07 AM


Document Has Been Signed on 08/24/2022 11:53 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
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:
08/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Fubara JackTIME COMPLETED:
12:15 PM
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On 8/24/22 at 9:10am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection to address concerns regarding an incident report dated 8/22/22 alleging a resident personal rights violation.

LPA Gould met with Licensee Fubara Jack, and together discussed the reported allegations made by R1. LPA conducted an interview with R1, Reviewed R1's file and reviewed the file for S1. LPA Gould obtained contact information for R1's authorized representative and the contact information for S1. LPA conducted an additional interview with S2.

Additional interviews and documentation will be reviewed before a determination can be made regarding the reported allegations.

While at the facility, LPA Gould observed a cracked window. LPA confirmed with Licensee the window replacement has been ordered and is on back order. At this time LPA did not observe the crack to be an immediate danger to residents in care and LPA asked Licensee if the crack gets larger or the window breaks to ensure all broken glass is removed to ensure resident safety. LPA issued an advisory note to document the cracked window and steps facility is taking to fix the window.

There were no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the licensee and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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