342701129-8-2-2024-27-AS-KHOS-D83R88-20240812124730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:26:43 PM

Unfounded

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
05/17/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240517081550

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: 4	DATE:	08/02/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ibifubara Jack		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not assist resident with ambulating

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived to conduct an unannounced complaint visit to conclude teh investigation on 8/2/24 at 9:45a. LPA met with Ibifubara Jack, Administrator and stated the purpose of the visit. LPA conducted interviews of 2 caregivers, Administrator and resident #2 regarding Resident #1 (R1) on 5/20/24.
Regarding allegation, “Staff did not assist resident with ambulating”, LPA conducted interviews of residents who were present during todays visit. All residents and staff that were interviewed confirmed that the Air Conditioner is used as well as fans to keep the facility cool on hot days. R5 stated awareness that R1 would consume alcohol. LPA obtained information through interviews that S1 on 5/15/24 was checking on R1 who was initially on the bed then once returned S1 observed R1 to be on the floor. S1 asked if R1 had been drinking and R1 replied yes at which time S1 took photos of R1 to submit to the responsible party. R1 was not interviewed due to hospitalization and relocation. The relocation was not a result of this incident or any issues at the facility. LPA observed there is a policy in place for alcoholic beverage use and photos. R1's responsible was in agreement to receive photos of R1.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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-20240517081550

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: 08/02/2024

NARRATIVE

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Based on interviews of past and present residents (R2-R5), staff (S1-S2) and R1's responsible party, review of photos, video, and R1's facility file the allegation mentioned above is deemed unfounded.

The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, no deficiencies are being cited.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

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