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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701129
Report Date: 08/15/2025
Date Signed: 08/15/2025 03:00:23 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
05/27/2025 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250527111627
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: 3DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Jack IbifubaraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Due to lack of supervision, residents engaged in a verbal/physical altercation
Staff do not assist residents during the night hours
INVESTIGATION FINDINGS:
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On 8-15-25 at 1:43pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver findings for the allegations noted above. LPA met with Administrator Jack Ibifubara and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members and five residents in care. Additionally, LPA reviewed facility file documentation including facility staffing schedule, residents’ needs and services plans, admissions agreement, staff training documentation, facility care notes, various incident reports reported by facility, resident’s physician’s reports, various email communications, and other evidence of communication. LPA also conducted a facility observation on 6-5-25 as part of this investigation.
Allegation: Due to lack of supervision, residents engaged in a verbal/physical altercation. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that on or about 5-18-2025 at approximately 9:30pm, two residents engaged in a verbal altercation which escalated to threats of physical violence between the residents.
{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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 4
Control Number 27-AS-20250527111627
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: 08/15/2025
NARRATIVE
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During this incident a staff member was in her designated live in quarters sleeping and was made aware of the altercation after R2 knocked on her door. Staff member was awakened and began to intervene. It was further revealed through interviews and record reviews that although staff member was physically inside the facility, staff member was not present for purposes of immediate intervention. Additional interviews and record reviews revealed that additional supervision was necessary during this time period due to various resident activity leading to potential threats to other residents’ physical, verbal, and resident rights. As a result, it is determined that a lack of appropriate supervision was not in place during this time period and was necessary to initially address the altercation before further escalation. Based on evidence reviewed, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
Allegation: Staff do not assist residents during the night hours. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that although a staff member lives in the facility and occupies a separate living quarter, facility did not schedule a staff member for on-call care and supervision duties between the hours of 11pm and 7am. A review of facility’s LIC 500 personnel report dated 6-17-2025 indicated no on-call staff between 11pm and 7am. Interviews and record reviews further revealed various episodes prior to the above date in which resident2 (R2) required physical assistance at night and told there was no staff available to assist. Additionally, it was revealed through interviews and other evidence that various resident activity within facility occurred between 11pm and 7am prior to the above date which led to potential threats of residents’ physical and mental well-being as well as personal rights. This included a resident in care identified by staff as infringing on rights of other residents during the day, with same resident awake between 11pm and 7am ambulating throughout facility with no staff scheduled on duty. As a result, it is determined that the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Based on this investigation, citations are issued under Title 22, division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250527111627
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: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87411(a)
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Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidenced by:
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Licensee will submit a plan identifying the current need for additional staff and it’s associated staffing plan. Plan to be sent to LPA by POC due date.
Licensee will read regulation 87411(a) and submit a signed declaration to LPA by POC due date.
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Based on interviews and record reviews, a staff member was not available for an intervention necessary to prevent an escalated altercation between two residents. This posed a potential health, safety, and resident rights risk to residents in care.
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Type B
08/29/2025
Section Cited
CCR
87415(a)(1
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Night Supervision. (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m.…(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement was not met as evidence by:
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Licensee will develop and submit a revised staffing plan which includes available staff between 11pm and 7am. Plan to be sent to LPA by POC due date.
Licensee will read regulation 87415(a)(1) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record reviews, facility did not schedule a necessary on-call staff member to cover the hours of 11pm and 7am to meet resident needs. This posed a potential health, safety, and resident 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
05/27/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250527111627

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: DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Jack IbifubaraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not report incident to appropriate agencies
INVESTIGATION FINDINGS:
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On 8-15-25 at 1:43pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver findings for the allegation noted above. LPA met with Administrator Jack Ibifubara and explained the purpose of the visit. Allegation: Facility did not report incident to appropriate agencies . During this investigation, LPA conducted interviews with four staff members and five residents in care. Additionally, LPA reviewed facility file documentation including various incident reports reported by facility. Based on review of incident reports and fax confirmations, it was determined that Licensee submitted incident reports to Licensing department within regulatory time frames. As a result, there is not a preponderance of evidence to conclude Licensee did not report various incidents to licensing department, therefore, this allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4