342701129-2-15-2024-27-AS-KHOS-D2LQYQ-20240219113532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 02/15/2024
Date Signed: 02/15/2024 09:59:03 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
01/16/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240116082714

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:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ibifubara Jack		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Ibifubara Jack and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Jack, five residents (R1-R5), and four staff members (S1-S4). LPA Moleski reviewed R1’s file and S1’s file. S1 was disassociated from this facility’s roster as of January 15, 2024.

In interviews, R1 said that S1 pulled R1’s hair and hit R1 in the face. R1 was able to identify S1 as the alleged abuser based on a photograph of S1. LPA Moleski did not observe any bruises or other apparent injuries on R1. In an interview, S1 denied the allegations.

[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: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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-20240116082714

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: 02/15/2024

NARRATIVE

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In interviews, R2-R5 said they had not witnessed S1 physically abusing R1. In interviews, S2-S4 said they had not witnessed S1 hitting or otherwise physically abusing R1.

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

Based on interviews and observation, 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 during this visit. An exit interview was held and a copy of this report was left with Jack.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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