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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 11/23/2022
Date Signed: 11/28/2022 08:09:32 AM


Document Has Been Signed on 11/28/2022 08:09 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: 5DATE:
11/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Fubara JackTIME COMPLETED:
10:30 AM
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On 11/23/22 at 9:20am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced plan of correction (POC) inspection to ensure all deficiencies previously cited have been corrected.

LPA reviewed POC documents provided by the licensee that meets all required documentation.

A POC letter was generated and provided to the licensee.

Per California code of regulations, Title 22 there were no deficiencies observed or cited during today's inspection.

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: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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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