Serenity Care Villa - Sagewood

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not provide resident with requested records.

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} Substantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2025 · control 27-AS-20250602134656

Allegation investigated: Due to lack of supervision, residents engaged in a verbal/physical altercation Staff do not assist residents during the night hours

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 5-1the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 27-AS-20250527111627

Allegation investigated: Illegal eviction Resident not treated respectfully by staff.

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 resthe state’s words, verbatim · CDSS document, May 1, 2025 · control 27-AS-20241212102649

Allegation investigated: Staff did not provide adequate food service for resident. Staff did not provide medical attention for resident.

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] Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 16, 2025 · control 27-AS-20250414162751

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not assist resident with ambulating

Licensing Program Analyst (LPA) Victoria Brown arrived to conduct an unannounced complaint visit to conclude teh investigation on 8/2/24 at 9:45a. LPA met with Ibifubara Jack, Administrator and stated the purpose of the visit. LPA conducted interviews of 2 caregivers, Administrator and resident #2 regarding Resident #1 (R1) on 5/20/24. Regarding allegation, “Staff did not assist resident with ambulating”, LPA conducted interviews of residents who were present during todays visit. All residents and staff that were interviewed confirmed that the Air Conditioner is used as well as fans to keep the facility cool on hot days. R5 stated awareness that R1 would consume alcohol. LPA obtained information through interviews that S1 on 5/15/24 was checking on R1 who was initially on the bed then once returned S1 observed R1 to be on the floor. S1 asked if R1 had been drinking and R1 replied yes at which time S1 took photos of R1 to submit to the responsible party. R1 was not interviewed due to hothe state’s words, verbatim · CDSS document, Aug 2, 2024 · control 27-AS-20240517081550

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff hit resident

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. LPA Moleski interviewed Jack, five residents (R1-R5), and four staff members (S1-S4). LPA Moleski reviewed R1’s file and S1’s file. S1 was disassociated from this facility’s roster as of January 15, 2024. In interviews, R1 said that S1 pulled R1’s hair and hit R1 in the face. R1 was able to identify S1 as the alleged abuser based on a photograph of S1. LPA Moleski did not observe any bruises or other apparent injuries on R1. In an interview, S1 denied the allegations. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 15, 2024 · control 27-AS-20240116082714

Allegation investigated: Staff slapped resident in the face

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with facility administrator Ibifubara Jack over the phone and explained the purpose of the visit. Jack said staff member Doria Ofori could sign this report in his absence. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Jack, six residents (R1-R6), and two staff members (S1-S2). LPA Moleski reviewed R1’s file and S1’s file. In an interview, R1 said that, on or around December 5, 2023, S1 slapped him in the face in the facility’s backyard area. There were no witnesses to the event, according to R1. In an interview, S1 said that she yelled at R1, but did not hit him. In an interview, S2 said she had not witnessed S1 hitting any residents. In interviews, R2-R5 said they had not witnessed staff become physically violent with residents. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 18, 2024 · control 27-AS-20231206152114

Allegation investigated: Staff member did not treat resident with dignity and respect

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 and record review. LPA Moleski interviewed administrators Ibifubara Jack and Linda Jack, six residents (R1-R6), and two staff members (S1-S2). LPA Moleski reviewed R1’s file and S1’s file. In an interview, R1 said that, around the end of November 2023, R1 had told S1 that R1 wanted to kill himself. In response, S1 told R1 that she would help him, according to R1. R1 also said that S1 verbally abused him regularly, that she yelled at him and cursed at him. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Jan 11, 2024 · control 27-AS-20231215145234

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.