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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 11:56:32 AM


Document Has Been Signed on 03/04/2022 11:56 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:
09:05 AM
MET WITH:Ibifubara Jack, LicenseeTIME COMPLETED:
12:15 PM
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On 3/04/2022 at 9:05am Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa - Sagewood for the purpose of conducting a pre-licensing inspection. LPA met with Licensee, Ibifubara Jack and together conducted a tour of the home. The home is a single story home in a residential community. The home consists of six bedrooms, three bathrooms. One of the bedrooms are shared. All beds equipped with required linen and furniture and appropriate lighting. One of the bedrooms is a dedicated staff bedroom.

LPA and Licensee evaluated the physical plant to ensure the health and safety of future residents. Areas inspected are including but not limited to the kitchen, bedrooms, bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed all sharp objects and cleaning supplies are made inaccessible. Facility dining room has enough chairs and plate settings to meet the needs of the population. LPA observed all doors and windows in the facility are equipped with an alarm that will notify the facility staff of the location of the open door or window. The alarm sounds in a central location in the facility. LPA Gould observed some items remain to be discarded on the side of the yard and the wood around the new concrete ramp should be removed prior to licensure.

LPA measured the water temperature, temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. Component 3 orientation has been scheduled for 3/4/22 at 11:00am. An exit interview was conducted, and a copy of this report was left at the facility.
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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