<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 04/16/2025
Date Signed: 04/16/2025 03:27:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250414162751
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:
04/16/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ibifubara JackTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate food service for resident.
Staff did not provide medical attention for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski and ombudsman Ron Carrera arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Ibifubara Jack and explained the purpose of the visit.

LPA Moleski interviewed Jack, two residents (R1-R2) and two staff members (S1-S2.) In an interview, a resident (R1) alleged that they had been denied food service by a staff member (S1) on two occasions, on April 13 and 14, and that S1 had refused to provide arrangements for emergency medical services on one occasion, on April 8. R1 said that they hit their own hand while working on a project, and needed to go to the hospital. During that same interview, however, R1 said that another staff member (S2) did provide meals to them, and said that S1 did dial 911 on their behalf. R1 said that R2 witnessed at least one of these incidents and could corroborate their allegations.
[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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-20250414162751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In an interview, R2 said that R1 had been provided meals on both days mentioned above by S2. R2 said that meals are always provided to all residents, and snacks are provided between meals. R2 had not witnessed any incidents where staff members denied meal services to residents. R2 said that on April 8, R1 came out to show them their swollen hand. R2 said that R1 informed S1 that R1 needed to go to the hospital, and S1 called medical services. R2 said that S1 said they did not have all of R1's personal information, so handed the phone to them to speak with first responders.

In an interview, S1 said that on April 13, R1 had gone for a walk but came back after the usual lunch time. S1 said that when R1 came in, they asked for their meal. S1 said the meal had already been prepared, but R1 continued to get upset. S1 said that S2 gave R1 their food without further incident. On April 14, S1 said they had been trying to find R1 to bring them to lunch, but couldn't find them. S1 said that they checked R1's room, and didn't see them in there. S1 said R1 may have been visiting friends across the street, or may have been in the bathroom. S1 said that R1 came into the kitchen, they asked for their meal. S1 said that R1 was then provided with their meal. S1 said that, on April 8, they had dialed emergency services for R1 upon their request, but handed the phone to them to speak with first responders because they did not have all of R1's information.

In an interview, S2 said that they had provided meals to R1 on both April 13 and 14, and said that no staff members had denied food service to R1. In an interview, Jack said he was present on April 13, and did not witness any staff members denying food service to R1.

The department has determined the following as it relates to the allegations that staff did not provide adequate food service for a resident and that staff did not provide medical attention for a resident:

Based on interviews, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Jack.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2