342701363-8-7-2025-27-AS-SRIN-DLN22Q-20250918170106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701363
Report Date: 08/07/2025
Date Signed: 08/07/2025 10:22:26 AM

Unsubstantiated

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
04/28/2025 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250428140532

FACILITY NAME:	IVY PARK AT SACRAMENTO		FACILITY NUMBER:	342701363
ADMINISTRATOR:	WEININGER, SARA		FACILITY TYPE:	740
ADDRESS:	345 MUNROE STREET		TELEPHONE:	(916) 486-0200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	70	CENSUS: 59	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sara Weininger		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident was sexually abused while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint. 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, nine staff members (S1-S9) and a resident (R1). LPA Kimberly Viarella interviewed R1’s responsible party (F1).

In an interview, R1 said that a male staff member forcibly inserted a tampon into their vagina. R1 was unable to identify when this occurred, or who the staff member was. R1 suggested a first name for the staff member, but was not positive if it was correct. S3 has that same first name.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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 3

Control Number 27-AS-20250428140532

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: 08/07/2025

NARRATIVE

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In an interview, Weininger said R1 first made these claims on the morning of April 22, 2025, and initially claimed that the incident had happened the night prior. LPA Moleski reviewed staff schedules and observed no male staff members were working in assisted living at any point on April 21 or 22. According to staff schedules and assignment sheets, S2, a male caregiver, was working during afternoon hours in assisted living on April 20, but was not assigned to provide any care for R1.

There were only three male caregivers on staff at the time these allegations were made (S1-S3). In interviews, S1-S3 denied having any information regarding the allegations.

LPA Moleski spoke with two staff members who worked with R1 on the morning of April 22 (S4 & S8). S4 said that R1 was bleeding, but it may have been rectal bleeding from R1’s hemorrhoids. S4 did not report finding any tampon inside of R1. S8 confirmed that they had assisted R1 to the bathroom and did not observe any tampon or other foreign objects in R1.

In an interview, the nighttime caregiver assigned to R1 on April 20 and 21 (S9) said they recalled R1 was having some bleeding around that time, however, they did not observe any unusual occurrences at the time, and did not observe any male staff entering R1’s room.

LPA Moleski reviewed charting notes related to R1’s care. A note dated April 21 indicated that R1 was suffering from rectal bleeding. A follow up note dated April 28 indicated that blood was observed in R1's urine. Another note dated April 29 indicated that R1 was prescribed an antibiotic for a suspected urinary tract infection. LPA Moleski reviewed R1’s medical assessment, dated 8/9/24. R1 was diagnosed with dementia, and was noted to suffer from confusion and disorientation.

In interviews, multiple staff members (S1, S2, S4, S5, S8, & S9) said they had observed R1 hallucinating previously. These staff members said that R1 has observed people in their room who were not actually present, and sometimes asks for confirmation from others if they can see the hallucinations as well.

S5 said that occasionally they will bring tampons for their own personal use, but said there are not any tampons regularly stored in the building. Other staff members who were interviewed said that tampons were not kept anywhere the facility. [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20250428140532

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: 08/07/2025

NARRATIVE

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The department has determined the following as it relates to the allegation that a resident was sexually abused while in care:

Based on interviews 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 during this visit. An exit interview was held and a copy of this report was left with Weininger.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

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