342701129-1-18-2024-27-AS-KHOS-CZRKM2-20240123070049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:06:11 AM

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
12/06/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231206152114

FACILITY NAME:	SERENITY CARE VILLA - SAGEWOOD		FACILITY NUMBER:	342701129
ADMINISTRATOR:	JACK, IBIFUBARA THEODORE		FACILITY TYPE:	740
ADDRESS:	3217 SAGEWOOD COURT		TELEPHONE:	(916) 598-8989
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	6	CENSUS: 5	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Doria Ofori		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff slapped resident in the face

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with facility administrator Ibifubara Jack over the phone and explained the purpose of the visit. Jack said staff member Doria Ofori could sign this report in his absence.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Jack, six residents (R1-R6), and two staff members (S1-S2). LPA Moleski reviewed R1’s file and S1’s file.

In an interview, R1 said that, on or around December 5, 2023, S1 slapped him in the face in the facility’s backyard area. There were no witnesses to the event, according to R1. In an interview, S1 said that she yelled at R1, but did not hit him.

In an interview, S2 said she had not witnessed S1 hitting any residents. In interviews, R2-R5 said they had not witnessed staff become physically violent with residents. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231206152114

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 - SAGEWOOD	FACILITY NUMBER: 342701129
	VISIT DATE: 01/18/2024

NARRATIVE

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In an interview, a Sacramento County deputy who had responded to the facility after the allegation was made said the alleged incident did not appear to have occurred.

LPA Moleski spoke with R1 in person on 12/11/23 and 12/28/23. LPA Moleski did not observe any suspicious marks or injuries on R1.

The department has determined the following as it relates to the allegation that staff slapped a resident in the face:

Based on interviews and observations, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Ofori.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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