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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 05/01/2025
Date Signed: 05/01/2025 04:23:29 PM

Substantiated


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
12/12/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241212102649
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:
05/01/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ibifubara JackTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Illegal eviction
Resident not treated respectfully by staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Ibifubara Jack and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. Six residents (R1-R6) and six staff members (S1-S6) were interviewed. LPA Moleski reviewed two residents' (R1 and R6) files. Jack provided LPA Moleski with copies of two eviction notices served to a resident (R1) on December 12, 2024 and January 11, 2025. LPA Moleski was provided copies of the same eviction notices, which appeared to be signed by Jack, from R1. The first notice, dated Dec. 12, 2024, indicates that R1 was to be evicted because R1 received an end-of-service notice from the agency paying for their residency as of Dec. 15. Additionally, the notice indicated that R1 was "cleared by [their] physician" and no longer needed their current level of care. Per 22 CCR Section 87224(a), a resident may be evicted for nonpayment of their basic rate, but 10 days must elapse past the due date. 22 CCR Section 87224(a) also permits eviction due to the identification of needs not previously identified upon initial appraisal. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
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 7
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
12/12/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241212102649

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:
05/01/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ibifubara JackTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not repositioning resident resulting in a pressure injury.
Licensee threatened resident.
Staff not providing assistance with activities of daily living.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Ibifubara Jack and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. Six residents (R1-R6) and six staff members (S1-S6) were interviewed. LPA Moleski reviewed two residents' (R1 and R6) files.

R6 was admitted as of 12/3/24, according to R6's admission agreement. R6's LIC 602, dated 10/15/2024, diagnosed R1 as paraplegic. No cognitive deficits were identified. R6 was identified as non-ambulatory, which means that the resident should be able to turn, rotate, and/or reposition themselves in bed. R6's initial appraisal, dated 12/3/24, indicated R6 had bilateral feet wounds, and stated that R6's heel must be "off load" at all times.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20241212102649
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: 05/01/2025
NARRATIVE
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R6 needed one person assistance transferring, according to the appraisal. R6 did not need special overnight supervision, according to the appraisal. The appraisal is signed and dated by R6. A needs and services plan for R6 dated 12/3/24 indicated R6 needed assistance with transfers to and from their wheelchair and assistance with their ADLs. However, no mention of turning or repositioning was made in R6's needs and services plan. The plan was signed by R6.

LPA Moleski reviewed medical records from a hospital visit for R6 dated 12/18/24. R6 was diagnosed with wounds to the left heel and right ankle, which were not staged. The wound on R6's left heel was described as a "deep pressure wound. Soft and boggy to touch. Deep purple in color. No open skin noted." The wound on R6's right heel was described as a "small wound. No surrounding erythema, no drainage." Older medical paperwork dated 11/13/24 also diagnosed R6 with bilateral foot wounds, similarly unstaged.

In an interview, R6 said they were at least partially able to reposition themselves, and said that they sometimes receive staff assistance with transferring to and from bed. R6 said they are sometimes able to transfer on their own. R6 said they receive care when they request assistance, and said that if they require nighttime assistance, they can call for the live-in caregiver (S1) and they will respond. On 3/4/25, R6 was observed to have small scabs or blisters on their heel. The wound was not open, but was difficult to assess due to the scabbing. R1 said that the wound was assessed by medical professionals on 12/18/24, who said that they were "not even stage one," according to R1.

Interviews with staff suggest that R1 was provided with barrier cream treatments and attempts were made to elevate R1's feet at night in order to reduce pressure.

In an interview, a resident (R1) alleged that care is provided at this facility only from 7 a.m. to 7 p.m. R1 alleged that staff members have refused to provide care and assistance to them, including refusing to empty their urinal containers. R1 also alleged that they were threatened by the licensee.

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20241212102649
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: 05/01/2025
NARRATIVE
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All other residents interviewed reported that they receive care at any time when they need assistance. S1, the live-in caregiver, said they will get up and respond to any resident if they need assistance. No concerns regarding care were voiced by other residents who were interviewed. Other residents interviewed did not voice specific concerns regarding the conduct of the licensee. However, R5 said they overheard an incident wherein the licensee told R1 something to the effect of "get out." R5 said it was in a "loud voice," but did not describe it as yelling. R5 said that the licensee has a naturally "big voice." R3 said they also overheard an incident wherein the licensee was discussing complaints made against staff with R1. R3 said the licensee may have been yelling, but they were in their room at the time and were not present to witness the interaction. In an interview, Jack said there was an occasion on or around Nov. 27, 2024, in which R1 was "belligerent." Jack said that he told R1 they were disturbing other residents and would have to leave if they continued. R1 said that on this date, the licensee had told them to pack their belongings and leave. Other residents and staff interviewed could not verify that this incident occurred as described by R1.

The department has determined the following as it relates to the allegations that staff are not repositioning a resident, resulting in a pressure injury, that the licensee threatened a resident, and that staff are not providing assistance with activities of daily living.

Based on interviews, observation, and record review, 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 regarding these allegations. 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: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20241212102649
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: 05/01/2025
NARRATIVE
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However, no provisions are made for eviction due to reduced needs. Additionally, eviction due to changing needs also requires a reappraisal to document the newly identified needs. No such reappraisal were present in R1's file. The notice did not contain a statement regarding unlawful detainers, as required by HSC Section 1569.683(a)(4). This initial eviction notice was rescinded after an advisement by LPA Kimberly Viarella.

The second notice, dated Jan. 11, 2025, indicated that R1 was being evicted due to non-payment of rent. According to the notice, The rent was due on Jan. 1, but was not received as of the date of the notice. The notice did not contain a statement regarding unlawful detainers, as required by HSC Section 1569.683(a)(4). In an interview, Jack said that this second notice was given in error, as payment arrangements had already been made by the agency paying for R1's stay. However, Jack said, he was not aware of this at the time. According to Jack, the notice was later rescinded after he was made aware of the updated payment arrangements.

Neither of the notices served were legal, based on 22 CCR and HSC requirements. However, this does not preclude the licensee from serving new, lawful eviction notices to R1 in the future. If the licensee chooses to pursue eviction, they agree to send a draft notice with all relevant supporting documents to CCLD for review.

In an interview, R1 said that a staff member (S6) locked them out of the facility on one occasion, and they had be let in by another resident. R1 said the incident occurred at the door leading into the backyard from the kitchen. In an interview, another resident (R6) said they had witnessed the incident as described above. R6 said the staff member "just wouldn't open the door" for R1. R6 said it seemed like the staff member didn't like R1. R6 said the staff member stared at R1 and laughed. R6 has no cognitive deficits or memory impairments, according to their medical records. In an interview, S6 said that they had locked the back door around 7 p.m., the end of their shift, while R1 was outside. S6 said R1 knew what time they typically locked up. S6 said that R1 "couldn't have been locked out" because there were multiple alternative entrances to the facility, such as the front door or R1's exterior bedroom door. S6 said they did not hear R1 calling to be let in.

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20241212102649
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: 05/01/2025
NARRATIVE
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Other residents and staff members interviewed did not report any rude behavior from staff members. In an interview, Jack said there was an occasion on or around Nov. 27, 2024, in which R1 was "belligerent." Jack said that he told R1 they were disturbing other residents and would have to leave if they continued. R1 said that on this date, the licensee had told them to pack their belongings and leave. Other residents and staff interviewed could not verify that this incident occurred as described by R1.

The department has determined the following as it relates to the allegation of illegal eviction and the allegation that a resident was not treated respectfully by staff:

Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87224(a) and 87468.1(a)(1). An exit interview was held with Jack. Appeal rights and a copy of this report were left with Jack.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20241212102649
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2025
Section Cited
CCR
87468.1(a)(1)
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"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding residents' rights. Licensee agrees to send LPA Moleski a schedule for the planned training by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews, a resident was not treated with respect by a staff member, which poses an immediate health, safety, and/or personal rights risk.
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Type B
05/15/2025
Section Cited
CCR
87224(a)
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"(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)." This requirement was not met as evidenced by:
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Licensee has already conferred with CCLD regarding future notices. Licensee agrees to provide LPA Moleski with a written statement acknowledging 22 CCR eviction procedures.
vincent.moleski@dss.ca.gov
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Based on record review and interviews, two unlawful eviction notices were served to a resident, which poses a potential 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7