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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:13:03 AM


Document Has Been Signed on 12/22/2023 10:13 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 4DATE:
12/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donnet PeartTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced in order to investigate complaints at this facility. LPA Moleski arrived and was met by two residents who opened the front door. LPA Moleski asked if staff were present at the facility, and the residents told LPA Moleski the staff member was across the street. The residents allowed LPA Moleski into the facility, where LPA Moleski observed there were no staff present.

LPA Moleski called Linda Jack and explained the purpose of the visit. Jack said staff member Donnet Peart could sign this report in her absence.

Peart returned to the facility around 9:40 a.m. The facility was unstaffed and without supervision for at least 40 minutes. Peart said she was working at a room and board across the street.

While the facility was unsupervised, LPA Moleski observed a cabinet containing cleaning solutions under the kitchen sink left unlocked. LPA Moleski also observed a broken glass light fixture, with exposed sharp glass, hanging over a counter within arms reach. Peart said the fixture had been broken for several months.

This facility is being cited per 22 CCR Sections 87411(a), 87309(a), and 87303(a). An exit interview was held with Jack. Appeal rights and a copy of this report was left with Peart.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 3


Document Has Been Signed on 12/22/2023 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2023
Section Cited
CCR
87411(a)

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"Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."

This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training on supervision. Licensee agrees to email LPA Moleski a training sign-in sheet.
vincent.moleski@dss.ca.gov
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Based on observation, no staff were present in the facility on the morning of 12/22/23, which poses an immediate health and safety risk.
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Type A
12/23/2023
Section Cited
CCR87309(a)

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"Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients."

This requirement was not met as evidenced by:
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Staff member locked up cleaning solutions during this visit. This plan of correction will be cleared.
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Based on observation, cleaning solutions were left unlocked and accessible without supervision, which poses an immediate health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/22/2023 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2023
Section Cited
CCR
87303(a)

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"The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors."

This requirement was not met as evidenced by:
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Licensee agrees to address the broken fixture, either by removing it or having it repaired, by the POC due date. Licensee shall send LPA Moleski a photograph of the solution by the POC due date.
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Based on observation, a glass light fixture was broken and was not repaired. The fixture was within arms reach and posed an immediate health and safety risk due to risk of residents cutting themselves on the broken glass.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
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