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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701363
Report Date: 07/14/2025
Date Signed: 07/14/2025 10:59:28 AM

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
01/28/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250128083443
FACILITY NAME:IVY PARK AT SACRAMENTOFACILITY NUMBER:
342701363
ADMINISTRATOR:WEININGER, SARAFACILITY TYPE:
740
ADDRESS:345 MUNROE STREETTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:70CENSUS: 54DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sara WeiningerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not assist resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Sara Weininger and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed Weininger, five staff members (S1-S5), and seven residents (R1-R7).

In an interview, a staff member (S1) said they observed a resident (R1) not wearing any pajama pants during their NOC shift on 1/17/25. According to S1, R1 said they did not know where their pants were and that the previous shift would not help R1. S1 said they then assisted R1 into their pajama pants. S1 said that R1 gets cold easily and will have leg cramps if they go to bed without pajama pants. S1 said they had also seen R1 without their pajama pants on two previous occasions. In an interview, R1 said that staff sometimes can’t find their pajama pants. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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
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
01/28/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250128083443

FACILITY NAME:IVY PARK AT SACRAMENTOFACILITY NUMBER:
342701363
ADMINISTRATOR:WEININGER, SARAFACILITY TYPE:
740
ADDRESS:345 MUNROE STREETTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:70CENSUS: 54DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sara WeiningerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff yells at residents
Staff threatens residents
Staff are restricting food/drink from resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Sara Weininger and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed Weininger, five staff members (S1-S5), and seven residents (R1-R7).

In an interview, a staff member (S1) said they had heard other staff members saying that they yell at residents, and that they sometimes threaten to withhold care to residents.

LPA Moleski interviewed a resident (R1) identified by S1 as having been threatened by staff. R1 said that all but one staff member was kind to them. R1 could not remember additional details, such as who the staff member was, or what happened. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20250128083443
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: IVY PARK AT SACRAMENTO
FACILITY NUMBER: 342701363
VISIT DATE: 07/14/2025
NARRATIVE
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LPA Moleski interviewed six other residents (R2-R6). R2 said that once, a staff member yelled at them. However, R2 said that they did not remember who the staff member was, or what exactly had happened. R3-R7 reported no concerns regarding staff conduct. S2-S5 reported no concerns regarding staff conduct.

S1 also said they had seen on daily care task sheets handwritten notes indicating that R1 could not have alcohol or sweets. LPA Moleski interviewed R1 in their room on 2/4/25, and observed alcohol and sweets present and accessible to R1. In an interview, R1 said that staff do not restrict their diet.

LPA Moleski reviewed daily care task sheets for the months of December and January and observed no notes indicating R1’s diet was to be restricted. LPA Moleski reviewed R1’s individual service plan, dated 8/27/24, which indicated R1 had no dietary restrictions. LPA Moleski reviewed R1’s LIC 602, which indicated that R1 consumes alcohol, and did not require any special dietary restrictions.

In interviews, multiple staff members said that, several months prior to this complaint being filed, R1 was drinking to excess, and suffered at least one fall around the same time. S2 said that staff were encouraging R1 to drink less, to avoid falling while inebriated. S4 said that staff were encouraging R1 to drink less to avoid negative complications with painkillers he was taking at the time. Both S2 and S4 said that R1 was allowed to drink as much as they wanted if they wanted more.

The department has determined the following as it relates to the allegations that staff yell at residents, that staff threaten residents, and that staff are restricting food/drink from a resident:

Based on interviews, record review, 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 regarding the above allegations. An exit interview was held and a copy of this report was left with Weininger.

This report was amended to correct an error in the use of confidential code identifiers.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20250128083443
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: IVY PARK AT SACRAMENTO
FACILITY NUMBER: 342701363
VISIT DATE: 07/14/2025
NARRATIVE
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LPA Moleski interviewed the two staff members who were working with R1 during the previous PM shift (S2-S3).

S2 said that they do not usually work with R1, so they did not know R1’s routine. S2 said that R1’s pajama pants weren’t available, as they were either in the washer or dryer. S2 said they told R1 they would get the pajama pants once they were clean, then took R1’s hearing aids out. LPA Moleski asked if R1 understood the situation and was fine with going to sleep without pajama pants. S2 said that they had already taken R1’s hearing aids out, so R1 wasn’t listening and kept talking over S2.

S3 said that they also rarely work with R1, and did not know at the time if R1 was going to urinate in bed. S3 said R1 was put to bed without pajama pants for that reason. S3 said R1’s pajama pants were in the dryer at the time. S3 said they tried to explain the situation, but R1 did not understand.

R1’s LIC 602, dated 2/22/24, indicated that R1 has a hearing impairment and uses hearing aids. R1’s individual service plan, dated 8/27/24, indicated that R1 "requires hands on assistance with dressing and undressing" and that "assistance with clothes selection" was included as part of this service. The plan stated that care staff were responsible for providing “hands on assistance choosing clothing, dressing and undressing" with an expected goal of maintaining "privacy, safety and comfort." The plan also indicated that R1 was hearing impaired and that R1 "needs assistance with hearing aid care," such as "donning and doffing hearing aids." R1’s preplacement appraisal, signed by Weininger on 1/25/23, states that R1 wears hearing aids, but even so is still “very hard of hearing,” and that R1 “needs help dressing.”

Title 22 of the California Code of Regulations (22 CCR) Section 87307 states that “equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available for each resident” and that the licensee shall assure provision of “basic laundry service.” Additionally, 22 CCR Section 87465(a)(3) states that “when residents require … hearing aids … the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed.” 22 CCR Section 87468.1(a)(12) grants residents the right “to wear their own clothes” and to “keep and use their own personal possessions.”

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20250128083443
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: IVY PARK AT SACRAMENTO
FACILITY NUMBER: 342701363
VISIT DATE: 07/14/2025
NARRATIVE
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The department has determined the following as it relates to the allegation that staff did not assist a resident.

Based on interviews and record review, 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 hereby cited per 22 CCR Section 87464(f)(4). An exit interview was held with Weininger. Appeal rights and a copy of this report were left with Weininger.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20250128083443
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: IVY PARK AT SACRAMENTO
FACILITY NUMBER: 342701363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
CCR
87464(f)(4)
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“(f) Basic services shall at a minimum include: … (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing … ” This requirement was not met as evidenced by:
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Licensee agrees to provide staff with training regarding personal rights and basic services, and agrees to provide LPA Moleski with a training record by POC due date. vincent.moleski@dss.ca.gov
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Based on interview and record review, a resident required assistance with dressing, with donning and doffing their hearing aid, and needed access to clean clothing as appropriate; however, on at least one occasion, this resident did not receive personal assistance as needed, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6