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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700834
Report Date: 05/21/2026
Date Signed: 05/21/2026 04:09:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260205132606
FACILITY NAME:SERENITY CARE VILLA INCORPORATEDFACILITY NUMBER:
342700834
ADMINISTRATOR:JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:7274 PRITCHARD ROADTELEPHONE:
(916) 376-7778
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Administrator: Geoffrey CurtisTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not prevent resident from developing wounds.
INVESTIGATION FINDINGS:
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On 05/21/2026 at 1:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Co- Administrator Geoffrey and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 6.

Allegation: Staff did not prevent resident from developing wounds
It was alleged that staff did not prevent resident from developing pressure wounds. This investigation consisted of interviews with facility staff, outside parties. On 2/06/2026, LPA Lee conducted a visit to the facility and collected resident records for R1. On 04/02/2026, SIA Hammond conducted interviews with 3 out of 3 facility staff. Staff (S1) stated that resident (R1) had a history of wounds on their toes which previously healed. S1 stated that while assisting R1 with their ADLs, bruising was observed on R1’s toes and the facility administrator was notified.

Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260205132606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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S1 further stated that the facility initiated wound care treatment, using an ointment on the affected areas of the resident. S1 stated that despite treatment efforts, the condition continued to worsen. Additional staff interviews revealed that R1 had a documented medical condition associated with bruising and skin breakdown of the feet. Staff stated that caregivers continued providing wound care within the facility and monitored the progression of the wounds. Interviews with outside parties indicated that R1’s wounds were not determined to be pressure injuries. It was reported that wounds were assessed as diabetic ulcers commonly occurring on the feet because of the resident’s medical condition and were not determined to be caused by neglect or lack of care within the facility. Based on the information and evidence obtained during the investigation, there was insufficient evidence to corroborate the allegation, therefore the allegation is unsubstantiated.


The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2026 and conducted by Evaluator Shakaricka Hughes
COMPLAINT CONTROL NUMBER: 27-AS-20260205132606

FACILITY NAME:SERENITY CARE VILLA INCORPORATEDFACILITY NUMBER:
342700834
ADMINISTRATOR:JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:7274 PRITCHARD ROADTELEPHONE:
(916) 376-7778
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Administrator: Geoffrey CurtisTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not report incident to appropriate parties.
Staff did not assist resident with obtaining medical care.
INVESTIGATION FINDINGS:
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On 05/21/2026 at 1:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Co-Administrator Geoffrey and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6.

Allegation: Staff did not assist resident with obtaining medical care.
It was alleged that staff did not assist resident with obtaining medical care. This investigation consisted of interviews with facility staff, and outside parties. On 2/6/2026 LPA Lee conducted a visit to the facility and collected resident records for R1. On 4/02/2026, SIA Hammond conducted interviews with 3 out of 3 facility staff. Interview with staff (S1) stated that wound care was initiated utilizing over-the-counter ointment; however, R1’s symptoms continued to worsen. Interview with the staff (S2) revealed that R1’s POA was not contacted immediately after staff initially observed the wound, as staff did not believe the wound appeared severe at that time.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260205132606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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Additional interview with the facility administrator/licensee revealed that approximately one month elapsed between the initial observation of the wound and R1 being transported to the emergency room for further medical evaluation. Interviews with outside parties indicated that wound care provided within the facility was insufficient to meet R1’s medical needs and that a higher level of medical treatment was necessary. R1 developed an infection associated with the prolonged presence of the wound and remained hospitalized for over the two months for treatment. Based on the information gathered during this investigation, this allegation was observed not in compliance with Title 22 regulation: 87465(a)(1) Incidental Medical and Dental Care as the facility did not ensure timely medical care for R1 after staff observed worsening of R1’s condition requiring further treatment.

Allegation: Staff did not report incident to appropriate parties

It was alleged that staff did not report incident to appropriate parties. This investigation consisted of interviews with facility staff, and records review. On 2/6/2026 LPA Lee conducted a visit to the facility and collected resident records for R1. On 4/02/2026, SIA Hammond conducted interviews with 3 out of 3 facility staff. Staff (S1) stated while assisting R1 with activities of daily living (ADLs), bruising were observed on R1’s toes and the facility administrator was notified of the concern. S1 stated that facility staff initiated wound care treatment within the facility, however, R1’s symptoms continued to worsen over time. Interview with Staff (S2) revealed that R1’s Responsible Party (RP) was not notified immediately after the wound was initially observed, as staff did not believe the condition appeared severe at that time. S2 revealed that they were notified by facility staff that R1’s condition continued to worsen over time, in which R1's, RP were eventually notified. Additional interviews revealed that approximately one month elapsed between the initial observation of the wound, notification to the POA and transport of R1 for medical evaluation. Records review revealed that on 7/11/2025, R1 was transported to UC Davis Medical Center due to an open wound on the left great toe requiring further medical treatment. Based on the information and evidence gathered during this investigation this was not observed in compliance with Title 22 regulation 87468.1 Personal Rights of Residents in All Facilities as the facility did not ensure timely notification of R1’s worsening medical condition.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Geoffrey and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility, a copy of this report will be emailed to the facility licensee/administrator.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260205132606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2026
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services...
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The facility administrator stated that training will be implementd on reporting requirements, and a procedure to document contact to POA/ RP. Additionally, the facility shall conduct training on facility reporting requirements.
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This requirement was not met as evidenced by:
As the facility did not ensure timely notification of R1’s worsening wound condition and need of medical evaluation after staff observed continued decline in their condition to R1's representatives. Which poses a health and safety risk to residents in care.
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and identifying changes in resident conditions and care needs. Training documents utilized and staff sign in sheets, shall be sent to LPA Hughes via email by 05/28/2026.
Type B
05/28/2026
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility....encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following.. (1) The licensee shall arrange, or assist in arranging...
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The licensee shall conduct training on facility reporting requirements, and identifying changes in resident conditions and care needs. Training documents utilized and staff sign in sheets, shall be sent to LPA Hughes via email by 05/28/2026.
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This requirement was not met as evidenced by:
As the facility did not ensure timely medical care for R1 after staff observed worsening of R1’s condition requiring further medical evaluation and treatment.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5