435202744-7-20-2026-26-AS-MMOR-DW6SPE-20260720140302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 07/20/2026
Date Signed: 07/20/2026 02:03:35 PM

Document Has Been Signed on 07/20/2026 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	IVY PARK AT MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR/ DIRECTOR:	MEGHIAN GEUL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY: 225		CENSUS: 208	DATE:	07/20/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

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	Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation (26-AS-20251110154451). The purpose of this case management-other visit was to review and address concerns identified during the investigation of the above referenced complaint that are unrelated to the allegation. LPA met with Administrator, Meghian Geul. Reporting Requirements During the complaint investigation, R1’s facility file record was reviewed and identified multiple documented falls and injuries involving R1 from 8/21/25 to 11/8/2025. Based on interview with ADM, ADM admitted that the required incident reports were not submitted to CCLD within the regulatory 7 days time frame. The Department reviewed R1’s Charting Notes (CN) with the following noted observations: On August 21, 2025, S2 observed discoloration on R1’s right lower leg and forehead that was a few days old, wherein R1 stated he/she had hit his/her head and denied falling. On October 23, 2025, R1 reported he/she had lost his/her balance and hit his/her head and sustained a bruise on his/her right check and right side of his/her chin. On October 24, 2025, Staff noted that R1 stated he/she bumped his/her head on the coffee table. R1 said the bruise to his/her face and chin was from a fall a few weeks ago. On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead. Continuation on LIC 809-C, Page 1 of 6.

Romeo Manzano
Manuel Monter
	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

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

LIC809 (FAS) - (06/04)

Page: 1 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 07/20/2026

NARRATIVE

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S5 stated R1 only required assistance with showering. S5 recalled assisting R1 with his/her ADLs once. S5 stated he/she was not working on 11/09/2025 and therefore was not aware of R1’s fall on that date. S5 stated he/she was not aware of how many falls R1 had experienced while at Ivy Park. S5 was also unable to provide information regarding what fall prevention measures were in place for R1 aside R1’s call button pendant.

S6 stated he/she never took care of R1 because R1 was independent but required assistance with showers. S6 stated R1 was “always falling” before he/she died. S6 recalled the last two falls R1 had before he/she was hospitalized.

S7 stated he/she did not know R1 and never met him/her. The Department explained that R1’s last care plan was completed on 07/05/2025. S7 stated that a re-assessment should have been done on 10/23/2025 and on 11/08/2025. S7 added that no one consulted with him/her nor asked him/her to conduct a re-assessment of R1. S7 believed R1 required a higher level of care than what he/she received. S7 said it was important that re-assessments were done in a timely manner.

The Department reviewed R1’s Charting Notes (CN) with the following noted observations:
On June 29, 2025, staff was letting W1 in when W1 informed him/her that R1 had fallen on June 28, 2025. Memory Care director assessed R1 and contacted 911.
On August 21, 2025, S2 observed discoloration on R1’s right lower leg and forehead that was a few days old, wherein R1 stated he/she had hit his/her head and denied falling.
On October 23, 2025, R1 reported he/she had lost his/her balance and hit his/her head and sustained a bruise on his/her right check and right side of his/her chin.
On October 24, 2025, Staff noted that R1 stated he/she bumped his/her head on the coffee table. R1 said the bruise to his/her face and chin was from a fall a few weeks ago.
On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 07/20/2026

NARRATIVE

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Reappraisals
During complaint investigation, it was noted that R1 requires assistance with bathing/showering but was otherwise generally independent. R1 used a walker due to mobility and visual and auditory impairment as per his/her Physician’s report, dated 04/14/2025.

The Department reviewed R1’s service plan, dated July 5, 2025. The service plan indicated that R1 requires maximum assistance with bathing. The service plan further documented that R1 did not require assistance with dressing, grooming, oral care, toileting, or transferring. R1 used a walker for mobility and was able to feed him/herself.

In April, May, & June 2026, the Department interviewed 5 staff (referred as S1, S4-S7).

S1 stated that although he/she had limited interactions with R1; S1 reported that the resident (R1) declined assistance on two occasions. S1 stated that staff are assigned to residents of each scheduled shift; staff have a list of residents assigned to them. S1 stated that he/she found it unusual that R1 was not included on the assignment list. S1 stated that while R1 can perform some of his/her ADLs, he/she still requires assistance and is not considered fully independent.

S4 stated he/she had only assisted R1 once or twice and he/she was not aware of R1’s medication regimen, as R4 self-managed his/her medications. S4 stated that he/she did not know whether R1 was identified as a fall risk; however, he/she is aware that R1 required two-hour checks.

The Department asked if an assessment would be done after R1 fell on 06/29/2025, possibly 08/21/2025, 10/23/2025, 11/08/2025, and 11/09/2025, and S4 said, “Yes. One should have been done for each fall.” S4 did not know whether one was done for each of R1’s falls. S4 recalled seeing a bruise on R1’s chin and neck but did not recall the date. S4 believed it may have been prior to R1’s hospitalization. S4 described the bruise as large and dark purple in color. S4 did not recall whether the bruise was documented in R1’s chart.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 07/20/2026

NARRATIVE

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S6 stated he/she never took care of R1 because R1 was generally independent but required assistance with showering. S6 stated that R1 had a history of frequent falls prior to his/her death and recalled the last two falls that occurred before R1 was hospitalized. S6 did not recall the date but said that R1 fell in the morning when his/her family was present, and in the evening after R1’s family left. S6 stated R1 was “okay” after falling in the evening and said that he/she was trying to get his/her phone from the side table. S6 stated he/she was trained to call 911 if a resident hit their head after a fall.

S7 stated if a resident hits their head after falling, it is an “automatic send out” to the hospital. S7 stated Ivy Park does not adhere to the fall prevention protocol and there are no prevention methods in place other than “just checking on them.” S7 stated he/she did not know R1 and never met him/her. S7 added that R1 should have been sent out following the evening fall on 11/08/2025 since she hit his/her head. S7 said that no one had reported R1’s falls to him/her, otherwise he/she would have sent R1 out to the hospital sooner.

The Department reviewed Local Fire Department Records. A review noted there were no calls for service between 11/06/2025 through 11/08/2025 for R1. A Review of Local Fire Department Patient Care Report states, on 11/09/2025, at or around 1721 hours, a 911 call was made for a complaint of altered level of consciousness. R1 had lost his/her hearing aid, had signs of old falls and bruising on his/her face, hands, and legs. Paramedics noted during their primary assessment that there were signs of old bruising, low blood sugar, and elevated heart rate. R1 was unable to communicate with EMS personnel and was transported to the hospital.

The Department Reviewed Local Law Enforcement Dispatch Reports. There were no calls for service for R1 on 11/8/2025.

Based on the investigation, there is no documented evidence indicating that the facility contacted 911 after Resident 1 (R1) sustained two falls on November 8, 2025. However, Staff 4 (S4) stated that R1 may have refused transport to the hospital; yet S4 was unable to provide documentation confirming that R1 declined or refused medical treatment or transportation. There is not a preponderance of evidence to prove nor disprove that the allegation, that the facility neglected to contact emergency services after R1’s fall on November 8, 2025. Page 3 of 6

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 07/20/2026

NARRATIVE

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The Department verified all incident reports (LIC624) submitted regarding R1 for the following date of incidents: 8/21/2025, 10/23/2025, 10/24/2025, 11/8/2025. Based on the review, the Department confirmed that the reports were not received. The ADM acknowledged that the required incident reports had not been submitted.

Arranging in Medical Care.
The Department reviewed R1’s Charting Notes (CN) with the following noted observations: On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead.

In April, May, & June 2026, the Department interviewed staff 4 staff (referred as S4-S7).

S4 stated he/she had only assisted R1 once or twice and he/she was not aware of R1’s medication regimen, as R4 self-managed his/her medications. S4 stated that he/she did not know whether R1 was identified as a fall risk; however, he/she is aware that R1 required two-hour checks.

The Department read S4’s notes that he/she documented and confirmed that R1 fell and hit his/her head on 11/08/2025 at 1915 hours, which S4 said, “Yes.” Initially S4 was unable to answer regarding why R1 was not sent out to the hospital on 11/08/2025 but later said that R1 may have refused to go to the hospital. S4 stated that staff would obtain a copy of the signed refusal from EMS and would document that 911 was called and that the resident refused to go to the hospital. S4 was unable to tell why it was not documented that 911 was called and that R1 refused to be sent to the hospital. The Department asked S4 about R1’s other falls on 06/28/2025, possibly 08/21/2025, and 10/23/2025 but S4 did not know anything about those falls and was unable to provide information about those falls. The Department requested a copy of the signed refusal and S4 said that staff never obtained a copy of the refusal and that EMS would have it.

S5 stated R1 was not under the medication management program and only required showering assistance. The Department showed S5 the charting notes from 11/08/2025, and S5 stated that R1 should have been sent out to the hospital because he/she hit his/her head. S5 stated If 911 was called and R1 refused to go to the hospital, it should have been documented as well. Page 2 of 6.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 07/20/2026 02:03 PM - It Cannot Be Edited

Created By: Manuel Monter On 07/20/2026 at 01:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/27/2026 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated she will conduct an inservice training with her staff and submit to CCL by POC due date. Administrator agreed and understood.
	8 9 10 11 12 13 14	Based on interviews and records reviewed of incident reports submitted to the Department, incident reports were not filed with the licensing agency regarding a change of condition wherein R1 had falls on 08/21/2025, 10/23/2025 and 11/08/2025, which poses/posed a potential health,	8 9 10 11 12 13 14	(con't) safety or personal rights risk to persons in care.
Type B 07/27/2026 Section Cited CCR87463(a)	1 2 3 4 5 6 7	87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated will conduct an inservice training with her staff and submit to CCL by POC due date. Administrator agreed and understood.
	8 9 10 11 12 13 14	Based on record review, R1 did not have a reappraisal after sustaining falls on 08/21/2025, 10/23/2025 and 11/08/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

Page: 8 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 07/20/2026

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 documents reviewed and interviews conducted, the facility did not re-assess resident R1 after he/she sustained falls in the facility on 08/21/2025, 10/23/2025, 11/08/2025. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Meghian Guel and a copy of the report and appeal rights were provided. Page 6 of 6

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC809 (FAS) - (06/04)

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