342701363-7-16-2026-27-AS-SRIN-DWPTYA-20260806150825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701363
Report Date: 07/16/2026
Date Signed: 07/16/2026 10:24:29 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
05/18/2026 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20260518134101

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: 57	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sara Weininger		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff do not properly assist resident with medication adminstration

INVESTIGATION FINDINGS:

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On July 16, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a follow-up investigation visit regarding the allegation noted above. LPA met with Executive Director/Administrator, Sara Weininger (AD) and stated the purpose of the visit.
It was alleged that staff were not properly assisting resident(s) with their medication. Specifically, staff were not helping a resident, R1, take his/her medication as per training and policy. Records and interviews indicated that R1 has a form of dementia diagnosis and needs help with medication management.
During the course of this investigation, LPA learned that at least two staff members gave R1 his/her medication and then left him/her alone with it, without staying to make sure he/she actually took it. AD confirmed that these situations happened. AD explained that one staff member left medication in R1’s room after R1 said he/she would “take it later,” another staff member handed R1 medication at the elevator in front of others, and a third staff member left the medication in R1’s room after R1 shut the door.
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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260518134101

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: 07/16/2026

NARRATIVE

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R1’s family also reported finding medication left in paper cups in R1’s room on several days in April and May 2026. They told AD, who said this was not acceptable and not the correct way to help with medication.

LPA reviewed training records that showed staff had been trained many times to watch residents take their medication, keep medication secure, document correctly, and follow the medication procedures and regulations.

Because staff left R1’s medication with R1 without watching R1 take it, the Department found the allegation substantiated. A finding that the complaint was substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

LPA noted that according to AD, they have retrained staff members who are assisting residents with medication administration which included one-on-one training and shadowing with each staff.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to CCR Title 22, Division 6 and Health and Safety Codes.

Plan of correction and appeal procedures were discussed with AD at the exit interview. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20260518134101

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: 07/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/30/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Per discussion with AD, prior to this visit, the facility initiated corrective action plans including retraining of staff members who are assisting residents with medication administration.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record reviews, staff did not properly assisted resident R1 with medication administration.On at least one occasion between April and May 2026, staff handed medication to R1 and left without confirming ingestion. This poses a potential health, safety, and/or personal rights risks to residents in care.	8 9 10 11 12 13 14	Per discussion, AD will submit a written plan on what have been done to ensure compliance. Plan and proof of retraining to be submitted to the Department by POC due date.
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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.

SUPERVISOR'S NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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