Serenity Care Villa - Sagewood

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Designated Staff, General Manager, Geoffrey Alexander Curtis. LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed the kitchen and dinning room area to be clean, sanitary, and organized. LPA Valerio observed an adequate food supply along with an emergency supply of food and water. LPA Valerio observed sharps, cleaning supplies, and The living room was observed to be fully furnished and organized. LPA observed a resident watching television in the living room. There was one care giver on shift who was assisting a resident with ADLs. The oncoming PM care staff, Victor, and AM care staff was observed to do shift exchange to discuss any important resident changes or task. LPA Valerio observed resident bedrooms to be fully furnished and free from odors. Resident bathroom was observed to be clean and sanitary. Hot water was measured within the regulatory range of 105-120 degrees F. The fire extinguisher was fully charged with the last inspection date of December 2025. LPA Valerio observed emergency exits to be free from obstructions. The backyard was observed to have a large area for outdoor activities and visitation. LPA Valerio reviewed staff file and resident file. All files were observed to be up to date with required annual documentation. LPA Valerio requested the following be sent to christina.valerio@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of liability insurance. Per California Code of Regulations (CCR) - Title 22 regulations - no deficiencies were observed. An exit interview was held, and a copy of this report was provided. LPA to email Administrator a copy via email.the state’s words, verbatim · CDSS document, Mar 23, 2026

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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Aug 29, 2025

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: 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.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: 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.

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 5-18-2025 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 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.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 27-AS-20250527111627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 29, 2025

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: 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.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(1 · Plan of correction due date: Aug 29, 2025

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: 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.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: 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.

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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 2, 2025

"(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: 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.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 15, 2025

"(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: 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.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: 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

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] Unsubstantiated In an interview, R2 said that R1 had been provided meals on both days mentioned above by S2. R2 said that meals are always provided to all residents, and snacks are provided between meals. R2 had not witnessed any incidents where staff members denied meal services to residents. R2 said that on April 8, R1 came out to show them their swollen hand. R2 said that R1 informed S1 that R1 needed to go to the hospital, and S1 called medical services. R2 said that S1 said they did not have all of R1's personal information, so handed the phone to them to speak with first responders. In an interview, S1 said that on April 13, R1 had gone for a walk but came back after the usual lunch time. S1 said that when R1 came in, they asked for their meal. S1 said the meal had already been prepared, but R1 continued to get upset. S1 said that S2 gave R1 their food without further incident. On April 14, S1 said they had been trying to find R1 to bring them to lunch, but couldn't find them. S1 said that they checked R1's room, and didn't see them in there. S1 said R1 may have been visiting friends across the street, or may have been in the bathroom. S1 said that R1 came into the kitchen, they asked for their meal. S1 said that R1 was then provided with their meal. S1 said that, on April 8, they had dialed emergency services for R1 upon their request, but handed the phone to them to speak with first responders because they did not have all of R1's information. In an interview, S2 said that they had provided meals to R1 on both April 13 and 14, and said that no staff members had denied food service to R1. In an interview, Jack said he was present on April 13, and did not witness any staff members denying food service to R1. The department has determined the following as it relates to the allegations that staff did not provide adequate food service for a resident and that staff did not provide medical attention for a resident: Based on interviews, 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 during this visit. An exit interview was held and a copy of this report was left with Jack.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 27-AS-20250414162751

Type of visit: Required - 1 Year

On 3/19/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator. LPA met with Ibifubara Jack and a brief interview followed. The Designated Facility Administrator also invited the House Manager to be present for the inspection. The House Manager and the LPA toured the facility. The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. LPA inspected 5 resident bedrooms and 1 staff bedroom. All resident rooms had the required furniture, furnishings, and lighting to be in compliance at this time. LPA noted soap, paper towels and tras hcans with lids in the bathrooms and well as grab bars and non-slip mats in the showers.. The hot water temperature was measured at 116.6 degrees Fahrenheit and was in compliance. The fire extinguisher was last serviced on 12/02/24 by Sacramento Fire Co. and was also in compliance. The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There were 2 storage sheds. One with a lock that contained chemicals and yard equipment. The second shed had storage items but nothing that would put residents at risk. There was also a covered patio area for residents to enjoy. The LPA observed medications were stored in a closet off the kitchen and inaccessible to residents in care. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance. LPA completed a review of of 3 resident and 3 staff files. All were complete and in compliance. According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's inspection. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation, but observed an unrelated deficiency. LPA Moleski met with administrator Geoffrey Curtis and explained the purpose of the visit. LPA Moleski observed a caregiver present (S1) and working at this facility. LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility. S1 said they had been working at this facility once a week for approximately two months. This facility is hereby cited per 22 CCR Section 87355(e)(3). A civil penalty in the amount of $100 per employee per day worked, with a maximum of five days assessed for a first-time offense, is hereby assessed, for a total of $500. An exit interview was held with Curtis. Appeal rights and a copy of this report were left with Curtis.the state’s words, verbatim · CDSS document, Mar 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Mar 5, 2025

"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)..." This requirement is not met as evidenced by: Based on observation, record review, and interview, S1 was working in this facility for at least five days without criminal record clearance association to this facility, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: LPA Moleski associated S1 during this visit. Licensee agrees to associate all other individuals from other facilities operated by the same individuals to this facility's roster by POC due date. Licensee shall provide LPA Moleski with an updated Guardian roster to show such changes have been made. vincent.moleski@dss.ca.gov

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 hospitalization and relocation. The relocation was not a result of this incident or any issues at the facility. LPA observed there is a policy in place for alcoholic beverage use and photos. R1's responsible was in agreement to receive photos of R1. Unfounded Based on interviews of past and present residents (R2-R5), staff (S1-S2) and R1's responsible party, review of photos, video, and R1's facility file the allegation mentioned above is deemed unfounded. The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, no deficiencies are being cited. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 27-AS-20240517081550

Type of visit: Case Management - Other

On 4/10/24 at 1:15pm Licensing Program Analyst (LPA) Kevin Gould arrived at Serenity Care Villa Sagewood 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 one 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

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] Unsubstantiated In interviews, R2-R5 said they had not witnessed S1 physically abusing R1. In interviews, S2-S4 said they had not witnessed S1 hitting or otherwise physically abusing R1. The department has determined the following as it relates to the allegation that staff hit a resident: Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Jack.the 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] Unsubstantiated In an interview, a Sacramento County deputy who had responded to the facility after the allegation was made said the alleged incident did not appear to have occurred. LPA Moleski spoke with R1 in person on 12/11/23 and 12/28/23. LPA Moleski did not observe any suspicious marks or injuries on R1. The department has determined the following as it relates to the allegation that staff slapped a resident in the face: Based on interviews and observations, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Ofori.the 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] Substantiated In an interview, S1 said the incident did not happen as described by R1. S1 described the incident only as a verbal conversation. In an interview, R5 said he had not seen S1 threaten R1 with a knife. R2, R3, and R4 had not witnessed staff become threatening or aggressive with clients. The department has determined the following as it relates to the allegation that a staff member threatened a resident while in care: Based on interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Jack. In interviews, S1 said that R1 often told her that he wanted to kill himself. “You always want to kill yourself. When you’re ready, let me know,” S1 said while recounting the incident described by R1. S1 said that she also informed R1 that the form of self-injurious behavior he was engaging in was not a sufficient way to kill oneself. S1 said that, after R1 asked if she would visit him after he died, S1 said nobody would visit him after he was cremated. S1 said that she and R1 took the discussion as a joke. S1 also said that, during an unrelated incident on or around December 5, 2023, she “yelled” and/or “shouted” at R1 because R1 was seeking attention from her. “Grow up and stop seeking attention,” S1 said while recounting the incident. In an interview, R2 said there are a few staff members who yell at residents when they are frustrated. R3 said staff get upset with him and sometimes yell at him. R4 had overheard arguments between staff and R1. R5 said S1 does not talk to people, but rather “barks at them.” R6 said staff do not treat her with respect. The department has determined the following as it relates to the allegation that a staff member did not treat a resident with dignity and respect: Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87468.1(a)(1). An exit interview was held and a copy of this report was left with Jack.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 27-AS-20231215145234

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 12, 2024

"(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: Based on interviews, R1 was not treated with respect or dignity by S1, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Licensee agrees to write a formal disciplinary statement for S1 by the POC due date. Licensee further agrees to conduct a staff training at a later date. Licensee agrees to email LPA Moleski a copy of the disciplinary statement by the POC due date, and a copy of the training sign-in sheet after the training is held. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Ibifubara Jack and explained the purpose of the visit. LPA Moleski reviewed two resident files (R1-R2) and two staff files (S1-S3). LPA Moleski utilized the Licensing Information System to review this facility's staff roster. LPA Moleski observed that the two staff members present at the facility when LPA Moleski arrived (S1 and S2) were not associated to the facility. LPA Moleski observed that two staff members who were previously observed to be providing care (S3 and S4) were also not associated to the facility. LPA Moleski toured the facility with Jack and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S1) and one resident (R3). This facility is being cited per 22 CCR Section 87355(e)(2). A civil penalty in the amount of $500 for a violation of criminal record clearance requirements was assessed. An exit interview was held with Jack. Appeal rights and a copy of this report was left with Jack.the state’s words, verbatim · CDSS document, Jan 11, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced in order to investigate complaints at this facility. LPA Moleski arrived and was met by two residents who opened the front door. LPA Moleski asked if staff were present at the facility, and the residents told LPA Moleski the staff member was across the street. The residents allowed LPA Moleski into the facility, where LPA Moleski observed there were no staff present. LPA Moleski called Linda Jack and explained the purpose of the visit. Jack said staff member Donnet Peart could sign this report in her absence. Peart returned to the facility around 9:40 a.m. The facility was unstaffed and without supervision for at least 40 minutes. Peart said she was working at a room and board across the street. While the facility was unsupervised, LPA Moleski observed a cabinet containing cleaning solutions under the kitchen sink left unlocked. LPA Moleski also observed a broken glass light fixture, with exposed sharp glass, hanging over a counter within arms reach. Peart said the fixture had been broken for several months. This facility is being cited per 22 CCR Sections 87411(a), 87309(a), and 87303(a). An exit interview was held with Jack. Appeal rights and a copy of this report was left with Peart.the state’s words, verbatim · CDSS document, Dec 22, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 23, 2023

"Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services." This requirement was not met as evidenced by: Based on observation, no staff were present in the facility on the morning of 12/22/23, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Licensee agrees to conduct a staff training on supervision. Licensee agrees to email LPA Moleski a training sign-in sheet. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Dec 23, 2023

"Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement was not met as evidenced by: Based on observation, cleaning solutions were left unlocked and accessible without supervision, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Staff member locked up cleaning solutions during this visit. This plan of correction will be cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 23, 2023

"The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors." This requirement was not met as evidenced by: Based on observation, a glass light fixture was broken and was not repaired. The fixture was within arms reach and posed an immediate health and safety risk due to risk of residents cutting themselves on the broken glass.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Licensee agrees to address the broken fixture, either by removing it or having it repaired, by the POC due date. Licensee shall send LPA Moleski a photograph of the solution by the POC due date.