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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:57:21 AM


Document Has Been Signed on 03/04/2022 11:57 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 - SAGEWOODFACILITY NUMBER:
342701129
ADMINISTRATOR:JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:3217 SAGEWOOD COURTTELEPHONE:
(916) 598-8989
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:6CENSUS: 0DATE:
03/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ibifubara Jack, LicenseeTIME COMPLETED:
12:15 PM
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On 3/4/22 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Licensee Ibifubara Jack via powerpoint presentation for Serenity Care Villa - Sagewood. LPA Gould conducted the component III with the licensee.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, and Health Related Services and Conditions.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted. Once approved, a copy of the license will be set to the Licensee.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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