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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:32:15 AM

Document Has Been Signed on 04/10/2024 10:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SERENITY CARE VILLA LLCFACILITY NUMBER:
342700834
ADMINISTRATOR/
DIRECTOR:		JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:7274 PRITCHARD ROADTELEPHONE:
(916) 376-7778
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ibifubara JackTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 4/10/24 at 10:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa LLC for the purpose of conducting an unannounced case management -deficiencies inspection to address observed medications requiring refrigeration stored in a refrigerator and not locked inaccessible to residents in care.

LPA observed insulin medications for three residents present in the fridge. LPA spoke with the licensee who immediately ordered a lock box for the refrigerated medications.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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 04/10/2024 10:32 AM - It Cannot Be Edited


Created By: Kevin Gould On 04/10/2024 at 10:16 AM
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: SERENITY CARE VILLA LLC
FACILITY NUMBER: 342700834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care: 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 was not met
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LPA observed licensee order a lock box for the medications stored in the fridge. Licensee will provide photos to LPA when medications are locked and stored inaccessible.
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as evidenced by, LPA observed refrigerator with insulin medications for three residents stored without a lock box or made inaccessible to residents in care which poses a potential health, safety or personal rights risk to residents in care.
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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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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