<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 03/09/2022
Date Signed: 03/23/2022 03:56:06 PM


Document Has Been Signed on 03/23/2022 03:56 PM - 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:
03/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ibifubara JackTIME COMPLETED:
09:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/9/22 at 9:10am Licensing Program Analysts (LPA) Kevin Gould arrived at Serenity Care Villa - Sagewood for a follow up Pre-licensing inspection to ensure all debris and construction items were removed from the back yard and no longer posed a potential health and safety risk to future residents. LPA met with licensee, Ibifubara Jack and together conducted a tour of the home.

LPA observed that all renovation items and debris had been removed from the side of the yard. LPA also observed the wood footings around the newly constructed concrete ramp on the side of the home had been removed.

LPA observed the home to be clean, odor free and in good repair. There are no barriers for the facility to be licensed. LPA will contact CAB and notify that pre-licensing has been completed and the facility is ready to be licensed.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. 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: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1