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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:32:19 AM

Document Has Been Signed on 03/04/2025 11:32 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/
DIRECTOR:		JACK, IBIFUBARA THEODOREFACILITY TYPE:
740
ADDRESS:3217 SAGEWOOD COURTTELEPHONE:
(916) 598-8989
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 6CENSUS: 5DATE:
03/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Geoffrey CurtisTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation, but observed an unrelated deficiency. LPA Moleski met with administrator Geoffrey Curtis and explained the purpose of the visit.

LPA Moleski observed a caregiver present (S1) and working at this facility. LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility. S1 said they had been working at this facility once a week for approximately two months.

This facility is hereby cited per 22 CCR Section 87355(e)(3). A civil penalty in the amount of $100 per employee per day worked, with a maximum of five days assessed for a first-time offense, is hereby assessed, for a total of $500.

An exit interview was held with Curtis. Appeal rights and a copy of this report were left with Curtis.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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Document Has Been Signed on 03/04/2025 11:32 AM - It Cannot Be Edited


Created By: Vincent Moleski On 03/04/2025 at 11:21 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
Section Cited
CCR
87355(e)(3)

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"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)..."

This requirement is not met as evidenced by:
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LPA Moleski associated S1 during this visit. Licensee agrees to associate all other individuals from other facilities operated by the same individuals to this facility's roster by POC due date. Licensee shall provide LPA Moleski with an updated Guardian roster to show such changes have been made.
vincent.moleski@dss.ca.gov
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Based on observation, record review, and interview, S1 was working in this facility for at least five days without criminal record clearance association to this facility, which poses an immediate health, safety, and/or personal rights 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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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