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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:36:04 PM

Document Has Been Signed on 11/04/2022 04:36 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: 6DATE:
11/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Serita ClarkeTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection at Serenity Care Villa -Sagewood on 11/4/22 at 2:00pm to address deficiencies observed while conducting an unrelated Complaint investigation.

Upon reviewing reviewing resident files, LPA observed 2 of 6 residents did not have a medical assessment on file. LPA also observed staff records to be incomplete. LPA observed one staff file to only contain COVID vaccination records and documented training. LPA did not observe Medical Assessment, Criminal record statement, First Aid certificate or signed mandated reporter agreement or employee information.

Additionally, When conducting file review LPA observed 1 resident was identified as bedridden. LPA observed the facility fire clearance is only approved for 6 non-ambulatory residents. LPA conducted interviews with two staff members who both attested to resident being unable to reposition in bed without assistance. Based on the information obtained and records reviewed this residents has been confirmed to be bedridden and the facility is not in compliance with the approved fire clearance.

The following deficiency is cited per California Code of Regulations, TITLE 22..

Exit interview was conducted facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 3
Document Has Been Signed on 11/04/2022 04:36 PM - It Cannot Be Edited


Created By: Kevin Gould On 11/04/2022 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY CARE VILLA - SAGEWOOD
FACILITY NUMBER: 342701129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2022
Section Cited
CCR
87606(c)

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Care of Bedridden Residents: To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement was not met as evidenced by LPAs review of resident records which indicates the facility has a fire clearance for 6
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Licensee will provide LPA with a written plan of correction indicating the steps facility will take to be in compliance with the approved fire clearance of 6 non-ambulatory residents.
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non-ambulatory residents but do not have a fire clearance for a bedridden resident. LPA observed the LIC 602 for 1 resident which indicates the resident is bedridden and staff interviewed confirmed resident is unable to rotate or reposition without assistance which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
11/05/2022
Section Cited
CCR87458(a)

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Medical Assessment: Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical
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Licensee will submit a written plan of correction indicating the steps the facility will take to become and remain in compliance with the regulation. Licensee will obtain medical assessments for all residents and ensure they are in the resident's file for review.
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assessment. This requirement was not met as evidenced by LPAs review or resident records which revealed 2 of 6 residents do not have a current medical assessment on file which poses an immediate health, safety and personal rights risk to
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/04/2022 04:36 PM - It Cannot Be Edited


Created By: Kevin Gould On 11/04/2022 at 04:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SERENITY CARE VILLA - SAGEWOOD
FACILITY NUMBER: 342701129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87412(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...This requirement was not met as evidenced by LPAs review of staff record where LPA observed one staff records only contained COVID vaccinations and hours of training which poses a potential health, safety and
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Licensee will submit a written plan of correction detailing the steps facility will take to ensure all staff files are complete and available to be inspected by the department. Licensee will ensure all files are complete by the POC due date.
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personal rights risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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