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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005180
Report Date: 10/06/2023
Date Signed: 10/06/2023 10:37:55 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
08/30/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230830162014
FACILITY NAME:IVY PARK AT SACRAMENTOFACILITY NUMBER:
347005180
ADMINISTRATOR:SARA WEININGERFACILITY TYPE:
740
ADDRESS:345 MUNROE STTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:70CENSUS: 61DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sarah WeiningerTIME COMPLETED:
10:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent an adult from being physically combative with resident at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/06/2023 at 9:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator, Sarah Weininger and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 61. A brief interview with conducted with administrator.

Allegation: Staff did not prevent an adult from being physically combative with resident at the facility.
It was alleged that staff did not prevent an adult from being physically combative with residents at the facility. This investigation consisted of records reviewed, interviews with staff, residents, and the residents responsible party. LPA Lee interviewed 9 out of 9 residents who stated residents have not witnessed any adult being physically combative toward residents in care. Furthermore, resident 1 (R1) denies an adult was being combative toward (R1). LPA Lee also interviewed 6 facility staff who denies witnessing any adult being physically combative with residents at the facility.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 4
Control Number 27-AS-20230830162014
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: 347005180
VISIT DATE: 10/06/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff did not prevent an adult from being physically combative with resident at the facility.

An exit interview was conducted, a copy of the LIC 9099 and LIC 9099-C was provided to the Facility Administrator, Sarah Weininger
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/30/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230830162014

FACILITY NAME:IVY PARK AT SACRAMENTOFACILITY NUMBER:
347005180
ADMINISTRATOR:SARA WEININGERFACILITY TYPE:
740
ADDRESS:345 MUNROE STTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:70CENSUS: 61DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sarah WeiningerTIME COMPLETED:
10:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident had a primary care provider.
Staff did not ensure that resident received timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/06/2023 at 10:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator, Sarah Weininger and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 61. A brief interview with conducted with administrator.

Allegation: Staff did not ensure that resident had a primary care provider
It was alleged that staff did not ensure that residents had a primary care provider. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. During the investigation it was learned that on 05/09/2023, UC Davis sent a message to resident 1 (R1) “My Chart” portol informing (R1) primary care physician (PCP) will no longer be with UC Davis and that (R1) will have a new (PCP). The facility was not aware of the (PCP) changes due to the fact that the facility does not have access to (R1) login information to “My Chart" portol.
Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230830162014
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: 347005180
VISIT DATE: 10/06/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Furthermore, it was discovered that responsible party 1 (RP1) did not read messages sent on 05/09/2023 to (R1) “My Chart" portal. (RP1) confirmed with LPA Lee that (RP1) did not login to read (R1) “My Chart” messages informing that (R1) has a change in (PCP).

Based on information provided through interviews and records reviewed, the department have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.


Allegation: Staff did not ensure that residents received timely medical attention.

It was alleged that staff did not ensure that residents received timely medical attention. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. During the investigation it was learned that resident responsible party 1 (RP1) made a doctor appointment for resident 1 (R1) and had cancelled the doctor appointment. The facility then received a phone call regarding the cancelation from UC Davis. The facility informed UC Davis that the facility will take (R1) to (R1) doctor appointment. Documentation reveals that on 08/31/2023 the facility facilitates in transporting (R1) to (R1) doctor appointment. On 09/29/203, (RP1) confirmed with LPA Lee that the facility transported (R1) to the appointment. Furthermore, it was also learned that (R1) had a follow-up appointment schedule for 09/06/2023 at 16:15 PM and that (RP1) was not able to transport and escort (R1) to the appointment and had asked the facility to help facilitate transportation for (R1).

Based on information provided through interviews and records reviewed, the department have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report LIC 9099-A and LIC 9099-C was provided to the facility administrator Sarah Weininger

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4