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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 02/09/2023
Date Signed: 02/10/2023 08:12:42 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221103160356
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:
02/09/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ibifubara JackTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Personal rights:
1) Staff handled resident in a rough manner
2) Facility staff slept in resident's bed without consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Serenity Care Villa - Sagewood on 2/9/23 at 1:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because former resident had no recollection of living at this facility and no recollection of any issues with staff. Former resident was able to identify issues at a previous room and board but not this facility. No other residents interviewed expressed no concerns or conflict with staff members or other residents. Staff interviewed also denied the allegations.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20221103160356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - SAGEWOOD
FACILITY NUMBER: 342701129
VISIT DATE: 02/09/2023
NARRATIVE
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There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, 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: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2