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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 03:43:41 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
06/02/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250602134656
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:
02:30 PM
MET WITH:Jack IbifubaraTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff did not provide resident with requested records.
INVESTIGATION FINDINGS:
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On 8-15-2025 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation 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 various email communications, and other evidence of communication.

Allegation: Staff did not provide resident with requested records. LPA conducted interviews and record reviews as noted above.

{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 6
Control Number 27-AS-20250602134656
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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Based on interviews and record reviews, it was revealed that R1 requested records on 4-24-2025 and 6-3-2025 which included physician reports, incident reports, care notes, admission agreement, itemized billing statements, licensing reports, and medical care related records. Based on interview and record review, it was determined that Licensee provided various records to R1 after requests, however, care notes were not released due to various other resident’s names and information attached as an inclusive internal record for staff to maintain. Investigation did not reveal evidence of physician reports and admission agreement sent to R1. Interview conducted revealed these documents were provided and available on admission, however, were requested by R1 after admission date. As a result, the preponderance of evidence standard is met, therefore, this allegation is SUBSTANTIATED. Citation is 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 6
Control Number 27-AS-20250602134656
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
87468.2(a)(19)
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87468.2 Additional personal rights of residents in privately owned facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records…This requirement was not met as evidenced by:
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R1 has since moved from facility with no forwarding contact information.
Licensee to read regulation 87468.2(a)(19) and submit a signed declaration of understanding to LPA by POC due date.
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 Based on interview and record review, R1 requested documents on two occasions, and no evidence existed to prove R1 received all documents. 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 6
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
06/02/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250602134656

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:
02:30 PM
MET WITH:Jack IbifubaraTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff did not ensure the home is kept free of bed bugs
Staff charged resident for services not rendered.
INVESTIGATION FINDINGS:
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On 8-15-2025 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived 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: Staff charged resident for services not rendered. LPA conducted interviews and record reviews as noted above. Based on record reviews, it was revealed that Resident1 (R1) admission agreement lists regulated basic services to be provided by the facility with an associated overall rate.

{Cont. on 9099C}
Unsubstantiated
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 6
Control Number 27-AS-20250602134656
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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Community Care Regulation (CCR) Section 87507(g)(3)(A) states in part: (g) Admission agreements shall specify the following: (3) Payment provisions including the following: (A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Additional interviews conducted did not reveal corroborated statements of additional residents being charged for services not rendered. An itemized bill furnished by facility indicating the services provided to R1 was reviewed. The investigation did not reveal evidence of said services not rendered. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff did not ensure the home is kept free of bed bugs. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that a room and board facility located across the street from licensed facility had a bed bug occurrence approximately nine months prior to the Department’s receipt of this complaint on 6-2-2025. It was further revealed that this occurrence was treated by facility’s licensee. Additionally, it was revealed that staff who worked at the room and board also worked at the licensed facility, however, maintained quarters in areas not affected by the bed bugs. Interviews and observation conducted did not reveal any evidence of a bed bug occurrence at any time within licensed facility. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

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: 5 of 6
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
06/02/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250602134656

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:
02:30 PM
MET WITH:Jack IbifubaraTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff did not provide resident with an itemized bill.
INVESTIGATION FINDINGS:
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On 8-15-2025 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation 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 one resident in care. Additionally, LPA reviewed facility file documentation including various email communications, and other evidence of communication including billing statement.

Allegation: Staff did not provide resident with itemized bill. Based on interviews and record review, it was revealed that a request for an itemized bill by resident1 (R1) which was provided to R1 and observed by LPA upon record review. Interviews conducted confirmed R1 received an itemized billing statement. As a result, the preponderance of evidence standard is not met, and 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: 6 of 6