Serenity Care Villa

Type of visit: Required - 1 Year

Licensing Program Manager (LPM) Arielle Pascua and Licensing Program Analyst (LPA) Mabel Cummings arrived at Serenity Care Villa Incorporated at 9:00 AM for the purpose of conducting a required 1 year annual inspection. LPM Pascua and LPA Cummings met with License, Ibifubara Theodore Jack and explained the purpose of the visit. Current census was 6. 1 out 6 residents were out at the hospital at the time of this visit. LPM, LPA, and licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPM and LPA observed the facility to be free of odor, clean and in good repair. LPM and LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPM and LPA observed the facility had three window/sliding door screens that were in need of repair. While inspecting the backyard, LPM and LPA observed fallen fruit from a fig tree covering the yard, creating a risk for pests. LPM and LPA observed an emergency exit door that was blocked and would not be usable in the case of an emergency. LPM and LPA observed the toilet in a restroom was not stable. LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPM and LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguisher was expired as of July 2026, and Licensee Fubara was able to get it serviced during the time of inspection LPM and LPA reviewed the staff and resident files, and noted the need for updated LIC625s for 6 of 6 residents. The needs and services for these clients did not provide adequate information to show the care the residents require. LPM and LPA reviewed the medications. LPM and LPA observed medications in an unlocked drawer located in the kitchen. Continued on LIC809-C. LPM and LPA observed their locked medication cabinet, finding an excess of medication bottles and bubble packs, organized in a way that makes it difficult to audit what medications have been administered. LPM and LPA have observed other cleaning supplies left in areas residents can access. LPM and LPA reviewed 4 staff records and 6 resident records. It was observed that 6 out 6 residents did not have an updated or completed LIC625, Needs and Services Plan on record. The following documents were requested to update the facility records: -LIC 308 -LIC 500 -LIC 610e -Liability insurance Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 24, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not prevent resident from developing wounds.

On 05/21/2026 at 1:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Co- Administrator Geoffrey and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 6. Allegation: Staff did not prevent resident from developing wounds It was alleged that staff did not prevent resident from developing pressure wounds. This investigation consisted of interviews with facility staff, outside parties. On 2/06/2026, LPA Lee conducted a visit to the facility and collected resident records for R1. On 04/02/2026, SIA Hammond conducted interviews with 3 out of 3 facility staff. Staff (S1) stated that resident (R1) had a history of wounds on their toes which previously healed. S1 stated that while assisting R1 with their ADLs, bruising was observed on R1’s toes and the facility administrator was notified. Continuation 9099-C Unsubstantiated S1 further stated that the facility initiated wound care treatment, using an ointment on the affected areas of the resident. S1 stated that despite treatment efforts, the condition continued to worsen. Additional staff interviews revealed that R1 had a documented medical condition associated with bruising and skin breakdown of the feet. Staff stated that caregivers continued providing wound care within the facility and monitored the progression of the wounds. Interviews with outside parties indicated that R1’s wounds were not determined to be pressure injuries. It was reported that wounds were assessed as diabetic ulcers commonly occurring on the feet because of the resident’s medical condition and were not determined to be caused by neglect or lack of care within the facility. Based on the information and evidence obtained during the investigation, there was insufficient evidence to corroborate the allegation, therefore the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Additional interview with the facility administrator/licensee revealed that approximately one month elapsed between the initial observation of the wound and R1 being transported to the emergency room for further medical evaluation. Interviews with outside parties indicated that wound care provided within the facility was insufficient to meet R1’s medical needs and that a higher level of medical treatment was necessary. R1 developed an infection associated with the prolonged presence of the wound and remained hospitalized for over the two months for treatment. Based on the information gathered during this investigation, this allegation was observed not in compliance with Title 22 regulation: 87465(a)(1) Incidental Medical and Dental Care as the facility did not ensure timely medical care for R1 after staff observed worsening of R1’s condition requiring further treatment. Allegation: Staff did not report incident to appropriate parties It was alleged that staff did not report incident to appropriate parties. This investigation consisted of interviews with facility staff, and records review. On 2/6/2026 LPA Lee conducted a visit to the facility and collected resident records for R1. On 4/02/2026, SIA Hammond conducted interviews with 3 out of 3 facility staff. Staff (S1) stated while assisting R1 with activities of daily living (ADLs), bruising were observed on R1’s toes and the facility administrator was notified of the concern. S1 stated that facility staff initiated wound care treatment within the facility, however, R1’s symptoms continued to worsen over time. Interview with Staff (S2) revealed that R1’s Responsible Party (RP) was not notified immediately after the wound was initially observed, as staff did not believe the condition appeared severe at that time. S2 revealed that they were notified by facility staff that R1’s condition continued to worsen over time, in which R1's, RP were eventually notified. Additional interviews revealed that approximately one month elapsed between the initial observation of the wound, notification to the POA and transport of R1 for medical evaluation. Records review revealed that on 7/11/2025, R1 was transported to UC Davis Medical Center due to an open wound on the left great toe requiring further medical treatment. Based on the information and evidence gathered during this investigation this was not observed in compliance with Title 22 regulation 87468.1 Personal Rights of Residents in All Facilities as the facility did not ensure timely notification of R1’s worsening medical condition. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Geoffrey and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility, a copy of this report will be emailed to the facility licensee/administrator.the state’s words, verbatim · CDSS document, May 21, 2026 · control 27-AS-20260205132606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: May 28, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services... This requirement was not met as evidenced by: As the facility did not ensure timely notification of R1’s worsening wound condition and need of medical evaluation after staff observed continued decline in their condition to R1's representatives. Which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: The facility administrator stated that training will be implementd on reporting requirements, and a procedure to document contact to POA/ RP. Additionally, the facility shall conduct training on facility reporting requirements. and identifying changes in resident conditions and care needs. Training documents utilized and staff sign in sheets, shall be sent to LPA Hughes via email by 05/28/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 28, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility....encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following.. (1) The licensee shall arrange, or assist in arranging... This requirement was not met as evidenced by: As the facility did not ensure timely medical care for R1 after staff observed worsening of R1’s condition requiring further medical evaluation and treatment.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: The licensee shall conduct training on facility reporting requirements, and identifying changes in resident conditions and care needs. Training documents utilized and staff sign in sheets, shall be sent to LPA Hughes via email by 05/28/2026.

Type of visit: Required - 1 Year

On 9/16/2025 at 12:30 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA met with the facility designated administrator Fubara, who accompanied LPA during the visit. The current census is 5 with 2 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 117.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 07/15/2025. LPA observed the facility has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 79 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 3 residents medications and the medication administration record (MAR) was not complete. LPA observed 3 out of 3 resident Medication Administration Record (MAR) incomplete, a record of daily dosages were not recorded for 3 days. Additionally, LPA observed resident medications transferred between containers. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 5 out of 5 resident files and they were complete. LPA reviewed 3 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 9/19/2025 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Fubara and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Required - 1 Year

On 9/19/24 at 1:45 Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa LLC for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Ibifubara Jack and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed there is a hot water dispenser that needs a caution sign. LPA observed one of the two staff files reviewed did not meet required hours in total annual training and specific dementia care training hours. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Other

On 4/10/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa LLC for the purpose of conducting an unannounced case management inspection to gather information and conduct interviews regarding compliance with labor law requirements. LPA met with Licensee, Ibifubara Jack. LPA conducted interviews with two staff members and the licensee. LPA requested payroll records and LPA would clarify what specific records to be requested. LPA requested LIC 500 (staff schedules) and was provided to LPA via email. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 10, 2024

Type of visit: Case Management - Deficiencies

On 4/10/24 at 10:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa LLC for the purpose of conducting an unannounced case management -deficiencies inspection to address observed medications requiring refrigeration stored in a refrigerator and not locked inaccessible to residents in care. LPA observed insulin medications for three residents present in the fridge. LPA spoke with the licensee who immediately ordered a lock box for the refrigerated medications. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 11, 2024

Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. this requirement was not met as evidenced by, LPA observed refrigerator with insulin medications for three residents stored without a lock box or made inaccessible to residents in care which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: LPA observed licensee order a lock box for the medications stored in the fridge. Licensee will provide photos to LPA when medications are locked and stored inaccessible.