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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 07/21/2023
Date Signed: 07/23/2023 02:55:53 PM


Document Has Been Signed on 07/23/2023 02:55 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 AC/SC, 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: 6DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Jack Ibifubara TheodoreTIME COMPLETED:
02:00 PM
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On 07/21/2023 at 8:05 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct caregiver, Doria Ofori, who then called administrator, Jack Ibifubara Theodore. Administrator arrived approximately an hour later. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6046173740 and will expire on 11/28/2023. The current census is 6 with three staff in the facility.

LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents at any given time. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven day non-perishable and two-way perishable food supplies. Hot water temperature was measured at 109.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 05/17/2023. LPA Lee observed the facility has a has a public telephone in the kitchen area and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 78 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 3 out of 6 medication administration record (MAR) sheet and it was not complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 3 out of 5 staff files and they were complete. LPA Lee also reviewed 6 out of 6 resident files and 6 out of 6 resident files were not complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SERENITY CARE VILLA LLC
FACILITY NUMBER: 342700834
VISIT DATE: 07/21/2023
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The following documents was given to LPA Lee during today's visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.

This page was created on accident. See other LIC 809-C Page

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SERENITY CARE VILLA LLC
FACILITY NUMBER: 342700834
VISIT DATE: 07/21/2023
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The following documents will be emailed to LPA Lee by 07/28/2023 by 5:00 PM by end of day.
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Proof of Current Liability Insurance
(4) LIC 610 Emergency Disaster Plan

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/23/2023 02:55 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SERENITY CARE VILLA LLC
FACILITY NUMBER: 342700834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457

(c) Prior to addmission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...
(2) Except as provided in Section 87638 (g)(3), if an initial appraisal or any reappraisal identifies an individual resident serivce...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. The licensee did not ensure that 6 out 6 residents had a current, accurate and complete LIC 625, Needs and Service Plan for resident and 3 out of 6 dementia residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee agrees to complete 6 out 6 resident's needs and service plan with resident or resident's family. Licensee agrees to email 6 out 6 LIC 625 to LPA Lee at pang.lee@dss.ca.gov by POC date by 5:00 PM by end of day.
Type B
Section Cited
CCR
87465

(a) A plan for incidental medical and dental care shall be developed by each facility...
(4) The licensee shall assist residents with self administerd medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, Licensee did not ensure that 3 out 3 MAR sheet were current and accurate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee agrees to update the MARS sheet. Licensee added 3 out 3 PRN medications onto the MAR sheets.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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