342700834-9-24-2026-27-AS-MCUS-DY8QXY-20260924123419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700834
Report Date: 09/24/2026
Date Signed: 09/24/2026 12:36:11 PM

Document Has Been Signed on 09/24/2026 12:36 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SERENITY CARE VILLA INCORPORATED		FACILITY NUMBER:	342700834
ADMINISTRATOR/ DIRECTOR:	JACK, IBIFUBARA THEODORE		FACILITY TYPE:	740
ADDRESS:	7274 PRITCHARD ROAD		TELEPHONE:	(916) 376-7778
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 6		CENSUS: 6	DATE:	09/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jack Fubara		TIME VISIT/ INSPECTION COMPLETED:	01:00 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 Manager (LPM) Arielle Pascua and Licensing Program Analyst (LPA) Mabel Cummings arrived at Serenity Care Villa Incorporated at 9:00 AM for the purpose of conducting a required 1 year annual inspection. LPM Pascua and LPA Cummings met with License, Ibifubara Theodore Jack and explained the purpose of the visit. Current census was 6. 1 out 6 residents were out at the hospital at the time of this visit. LPM, LPA, and licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPM and LPA observed the facility to be free of odor, clean and in good repair. LPM and LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPM and LPA observed the facility had three window/sliding door screens that were in need of repair. While inspecting the backyard, LPM and LPA observed fallen fruit from a fig tree covering the yard, creating a risk for pests. LPM and LPA observed an emergency exit door that was blocked and would not be usable in the case of an emergency. LPM and LPA observed the toilet in a restroom was not stable. LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPM and LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguisher was expired as of July 2026, and Licensee Fubara was able to get it serviced during the time of inspection LPM and LPA reviewed the staff and resident files, and noted the need for updated LIC625s for 6 of 6 residents. The needs and services for these clients did not provide adequate information to show the care the residents require. LPM and LPA reviewed the medications. LPM and LPA observed medications in an unlocked drawer located in the kitchen. Continued on LIC809-C.

Arielle Pascua
Mabel Cummings
	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 09/24/2026 12:36 PM - It Cannot Be Edited

Created By: Mabel Cummings On 09/24/2026 at 11:35 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 INCORPORATED	FACILITY NUMBER: 342700834
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring that 3 window screens and toilet were in good repair. In addition, the licensee did ensure that the yard was maintained to keep fallen fruit off the yard. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 10/01/2026
	Plan of Correction
1 2 3 4	Statement of Correction and Acknowledgement will be provided to LPA by POC date. Copies of services rendered will be provided upon completion.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not ensuring the exit door in Bedroom #2 was free of obstruction. LPA and LPM observed 3 bags of belongings blocking the exit door. This poses a potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 10/01/2026
	Plan of Correction
1 2 3 4	Licensee removed objects obstructing the exit door. Statement of Correction and Acknowledgement will be provided to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:

	Mabel Cummings
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2026 12:36 PM - It Cannot Be Edited

Created By: Mabel Cummings On 09/24/2026 at 11:35 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 INCORPORATED	FACILITY NUMBER: 342700834
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obersvations and interviews, the licensee did not comply with the section cited above by having medications in an unlocked kitchen drawer accessible to client and cleaning supplies in unlocked areas, which poses a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 10/01/2026
	Plan of Correction
1 2 3 4	Licensee removed available disinfectants during this visit. Statement of Correction and Acknowledgement will be provided to LPA by POC date.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having appraisals older than 12 months for 6 of 6 clients. The needs and services were not sufficient in content, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2026
	Plan of Correction
1 2 3 4	Statement of Correction and Acknowledgement will be provided to LPA by POC date. Copies of LIC625s will be provided upon completion.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:

	Mabel Cummings
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SERENITY CARE VILLA INCORPORATED	FACILITY NUMBER: 342700834
	VISIT DATE: 09/24/2026

NARRATIVE

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LPM and LPA observed their locked medication cabinet, finding an excess of medication bottles and bubble packs, organized in a way that makes it difficult to audit what medications have been administered. LPM and LPA have observed other cleaning supplies left in areas residents can access.

LPM and LPA reviewed 4 staff records and 6 resident records. It was observed that 6 out 6 residents did not have an updated or completed LIC625, Needs and Services Plan on record.

The following documents were requested to update the facility records:
-LIC 308
-LIC 500
-LIC 610e
-Liability insurance

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.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Mabel Cummings
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC809 (FAS) - (06/04)

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