Ivy Park at Sacramento.

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.

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. 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 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.

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.

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] 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 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.