Ivy Park at Sacramento

Allegation investigated: Staff do not properly assist resident with medication adminstration

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. {1 of 2} Substantiated 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.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 27-AS-20260518134101

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 30, 2026

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. 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.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: 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. 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.

Allegation investigated: Resident was sexually assaulted by staff while in care.

On 2/5/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannouced at this facility to conduct a follow-up complaint investigation and deliver findings regarding the allegations noted above. LPA met with the Executive Director/Administrator, Sara Weininger (AD) and stated the purpose of this visit. R1 disclosed to a hospice home health aide during a bed bath on 9/26/2025 that R1 had been “rape.” This concern was reported to hospice and facility staff and then to licensing. Facility staff responded promptly by checking on R1, completing a body check, and initiating an internal investigation. No injuries or signs of physical harm were observed during the assessment. {1 of 2} Unsubstantiated The investigation included a review of facility reports, medical records, and interviews. Facility records showed that R1 received bed baths on 9/23/2025 and 9/26/2025 by hospice staff, which matched the timing of R1’s statements. However, no staff reported witnessing or hearing R1 make similar statements outside of these incidents. Records confirmed that R1 has a diagnosis of Alzheimer’s dementia, with periods of confusion, disorientation, sundowning behaviors, and depression. Family members reported that R1 had made similar allegations in the past at another placement, which reportedly stopped after medication was prescribed and later R1’s allegations resumed when those medications were discontinued for hospice care. During a follow-up interview conducted on 10/23/2025 by the Department, R1 did not disclose any sexual assault. Due to the lack of physical evidence, the absence of witnesses, inconsistent disclosures, and R1’s documented cognitive impairment, there was insufficient evidence to confirm that a sexual assault occurred. The allegation that R1 was sexually assaulted by staff while in care could not be proven or disproven, and therefore the finding is UNSUBSTANTIATED. Note that an unsubstantiated finding 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 conducted with AD and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 27-AS-20251001102433

Type of visit: Case Management - Annual Continuation

On 10/09/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue the annual inspection that was initiated on 10/01/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director. LPA met with Sara Weininger and a brief interview followed. LPA observed 3 residents finishing up breakfast in the dining room of assisted living and 2 servers cleaning and setting up for lunch. LPA conducted an inspection of the kitchen on 10/01/25. The kitchen was inaccessible to residents in care. LPA observed that kitchen staff were wearing appropriate clothing, gloves, and long hair was secured appropriately at the time of the inspection. LPA inspected inventory of food and found it to be sufficient for 7-day perishable and 2-day non-perishable. All items were stored and dated appropriately and the fire extinguishers were last inspected on by Fire and Power Protection Co. on 01/29/25. The ED and LPA proceeded to visit 2 resident rooms in assisted living. All had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA inspected the bathrooms and observed hand soap, towels and trash cans along with grab bars and non-slip/skid surfaces in the showers. LPA measure the hot water in room 226 to ensure it was between the required 105 - 120 degrees Fahrenheit. The hot water measured 111.9 and was in compliance at the time of this inspection. LPA activated the call alert/pendant in room 224. Staff responded in 2.4 minutes. LPA and ED inspected the Medication Room in Assisted Living. LPA reviewed the administration, storage and destruction procedures with the medication tech on duty. LPA also inspected the first aid kit to ensure it had all the required elements. LPA observed 7 residents in assisted living participating in a morning fitness class in an activity room led by a staff member. LPA and ED toured memory care community where the LPA then inspected their Medication Room and reviewed the centrally stored medication logs. LPA inspected the medication cart and reviewed a sample of resident medications contained in the locked unit. LPA spoke to one resident who was well-groomed and sitting in main corridor "waiting for a ride." LPA also observed 4 residents in the dining area supervised by staff. The following materials were posted in the facility: "If You See Something, Say Something" and Ombudsman contact information posters, Resident Rights, grievance policy, calendar of activities, facility menus, and facility license. The ED and the LPA inspected the exterior of the facility. All screens and gutters were in good repair at the time of this inspection. There was a fenced in / courtyard area in memory care and a partially walled in area in assisted living; both had shaded areas and furniture for residents to enjoy. LPA also inspected the locked storage shed that contained the emergency food supply and extra furniture. A file review was conducted by the LPA. The staff roster was reviewed to ensure that all required employees had the appropriate background clearances. All were in compliance at the time of this inspection. Files were then reviewed for 3 residents. All were in compliance at the time of this inspection. LPA and ED discussed the different format for the two service plans utilized in different files and LPA provided technical assistance regarding information that should be included in each. The ED explained how the staff utilize workflow /assignment sheets to provide the necessary information that the electronic plans do not. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's inspection. A copy of this report was provided and an exit interview was conducted with Sara Weininger.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Post Licensing

On 10/01/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a post-licensing inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Sara Weininger and a brief interview followed. The ED shared that they were currently seeking to fill the position of Director of Maintenance as their previous Director was promoted within the company to another position. LPA and the ED then conducted a walkthrough of the facility. LPA noted the ED's certificate, # 7008349740 and it expires on 03/26/26. The inspection began in the kitchen. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. LPA pulled a sample of dry goods and items from the freezer and all were in compliance at the time of this inspection. LPA inspected 4 bedrooms 2 in memory care and 2 in assisted living. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels and trash cans with lids in the bathrooms. The fire extinguishers were last serviced on 01/29/25 by Power Air and Fire and were also in compliance. The exterior of the building was inspected by the LPA. There were no bodies of water present and there was a sitting area with shade and furniture in the front for residents to enjoy. LPA observed that all screens and gutters were in good repair. There were 2 storage sheds with locks that contained yard equipment and storage items. LPA observed that all medications were kept in locked medication carts or in 1 of the 2 locked medication rooms. LPA reviewed centrally stored medication log and a sample of residents' medications. All were in compliance at the time of this inspection. LPA compared the staff roster with the list of background clearances from Community Care Licensing (CCL). Out of the 80 staff members with background clearances, there was one additional employee who had a background clearance but who was not associated to this facility. This deficiency was cited on the LIC 809D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL rights.the state’s words, verbatim · CDSS document, Oct 1, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 10/01/25, 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 meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Sara Weininger and a brief interview followed. LPA began the inspection by comparing the guardian roster to the staff roster to ensure that all staff had their required background clearances. All staff were in compliance at the time of this inspection. Due to time constraints this LPA will have to return at a later date as this inspection requires more time to complete. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and exit interview was conducted with Sara Wieninger.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Resident was sexually abused while in care

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 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] 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.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 27-AS-20250428140532

Allegation investigated: Staff did not assist resident

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 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. 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] 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.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 27-AS-20250128083443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 18, 2025

“(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: 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.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: 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

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Victoria Brown arrived announced on 9/10/24 at 9:00am and met with Applicant Transformer OPCO LLC: Oakmont Management Group LLC representative Sara Weininger, Executive Director/Administrator and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the facility that will be licensed and fire cleared for a capacity of 70 non-ambulatory residents of which 7 maybe bedridden in rooms 105-107, 110, and 118-120 only. There are occupancy 52 rooms in the building. Administrator certificate expires on 3/26/2026. LPA observed that the facility has submitted a Infection Control Plan. LPA observed a Designation of Facility Responsibility (LIC308) on file. LPA and Sara Weininger toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, a random amount of bedrooms and bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 105.2 *F in several rooms which is within the required range of 105-120*F. The temperature inside the facility measured between 72-77 *F in several areas of the building which is within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed area for centrally stored medications to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s), pull alarms, and delayed egress system. Facility also has central heating and air. LPA reviews 4 resident and 4 staff files during this visit. Component III conducted - There are no objections to licensure at this time. -Licensure pending. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2024