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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701129
Report Date: 03/19/2025
Date Signed: 03/19/2025 04:08:02 PM

Document Has Been Signed on 03/19/2025 04:08 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
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: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ibifubara Jack TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 3/19/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator. LPA met with Ibifubara Jack and a brief interview followed.

The Designated Facility Administrator also invited the House Manager to be present for the inspection. The House Manager and the LPA toured the facility. The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately.

LPA inspected 5 resident bedrooms and 1 staff bedroom. All resident rooms had the required furniture, furnishings, and lighting to be in compliance at this time.

LPA noted soap, paper towels and tras hcans with lids in the bathrooms and well as grab bars and non-slip mats in the showers.. The hot water temperature was measured at 116.6 degrees Fahrenheit and was in compliance. The fire extinguisher was last serviced on 12/02/24 by Sacramento Fire Co. and was also in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There were 2 storage sheds. One with a lock that contained chemicals and yard equipment. The second shed had storage items but nothing that would put residents at risk. There was also a covered patio area for residents to enjoy.

The LPA observed medications were stored in a closet off the kitchen and inaccessible to residents in care.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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 2
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
VISIT DATE: 03/19/2025
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LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

LPA completed a review of of 3 resident and 3 staff files. All were complete and in compliance.

According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's inspection. A copy of this report was provided.

Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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