435202744-8-6-2026-26-AS-MMOR-DWPUZ6-20260806160100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 08/06/2026
Date Signed: 08/06/2026 04:01:18 PM

Document Has Been Signed on 08/06/2026 04:01 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: 211	DATE:	08/06/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Administrator Meghian Geul		TIME VISIT/ INSPECTION COMPLETED:	04:15 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-20260310091638). 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 November 22, 2025- February 24, 2026. The Department reviewed R1’s Progress Note with the following noted observations: November 22, 2025: at 5:15pm, care giver called the medtech, noting that R1 had fallen. R1 had slipped on the floor and hit his/her buttocks. R1 denied hitting his/her head. December 14, 2025: at 4:30pm, R1 pushed his/her pendant and the care giver found R1 sitting on his/her buttocks, in his/her apartment closest. R1 claims he/she did not hit his/her head and did not have pain. December 16, 2025: Per R1, he/she stated he/she had a fall last night at 4:00am. R1 denies hitting his/her head and pain. R1 appeared confused and stated that his/her belongings are missing. December 20, 2025: At 2:49am, R1 reported to care giver that he/she had a fall besides his/her chair. R1 was assisted back to his/her chair. No complaints of pain or discomfort. Staff noted skin tear about 2 inches wide on his/her right elbow. Cleaned wound and applied bandage. Page 1 Out of 4

Romeo Manzano
Manuel Monter
	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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

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: 08/06/2026

NARRATIVE

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The Department reviewed R1’s Service Plan, dated November 21, 2025. Based on a review, the service plan states R1 requires assistance with dressing in the morning, before breakfast daily. R1 requires escorting and or physical assistance to attend meals and or activities. R1 is at moderate risk for falling. Facility staff is to monitor for the use of glasses. Place pendant within reach of resident. Monitor and report changes in ambulation. The care team will monitor for changes in condition and conduct a reappraisal as appropriate.

The Department interviewed staff S2. During interview with S2, the Department showed S2 R1’s progress notes, which documented that R1 had fallen 11/22/25, 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, 2/24/2026. The Department also showed S2 R1’s care plan, dated November 21, 2025. The Department asked if an assessment would be done after R1 fell on 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, and/or 2/24/2026. S2 stated based on the number of falls experienced by R1 during that time period of December - February, R1’s plan of care should have been reassessed. S2 stated R1 required more care and supervision than what he/she had, including assistance with dressing, showering, and transferring.

On August 6, 2026, Licensing Program Analyst Manuel Monter interviewed Cathy Platon Health Services Director, referred to as HSD. The Department showed S2 R1’s progress notes, which documented that R1 had fallen 11/22/25, 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, 2/24/2026. The Department also showed S2 R1’s care plan, dated November 21, 2025. The Department asked if an assessment would be done after R1 fell on 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, and/or 2/24/2026. HSD stated based on the information presented regarding R1, there should have been an updated care plan or a care conference conducted to review R1's plan of care.

The Department reviewed R1’s progress notes and observed the following: After R1’s care plan had been updated, the resident sustained one unwitnessed fall in November 2026. R1 then sustained four unwitnessed falls in December 2025. Additionally, R1 sustained one unwitnessed fall in January 2026, one in February 2026, and one in March 2026.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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: 08/06/2026

NARRATIVE

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On July 20, 2026, the facility was cited a type B deficiency under the regulation the following regulation: 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.

LPA advised ADM to ensure the facility takes an active role in the residents care plans, ensuring that care plans are updated in writing as frequently as necessary to note significant changes in condition and to keep the appraisal accurate. LPA advised ADM to take note if residents in care are sustaining numerous falls, the evaluate (with the residents responsible party if applicable) if the residents care plan needs to be updated to meet the needs of the resident.

LPA provided ADM information regarding the Department’s Technical Support Program (TSP).

During today's visit, the Department is issuing 2 technical violations. This report was reviewed with Administrator Meghian Geul and a copy of the report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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: 08/06/2026

NARRATIVE

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December 23, 2025: At 10:27am, Care giver called for help, because he/she found R1 sitting on the floor. R1 denied hitting his/her head. Staff observed old skin tear on his/her right elbow bleeding.
January 31, 2026: Around 9:20pm, R1’s Family member called asking to help R1. Staff went to R1’s room to check on R1. R1 stated he/she had lost his/her balance and fell on the floor. R1 denies hitting his/her head. Staff noticed bruise on his/her left arm. R1 stated he/she had it for a long time, refused to call 911.
February 24, 2026: at 11:20am, R1 was found lying on the floor. R1 stated that he/she had a fall while reaching his/her computer table. R1 denied hitting his/her head. R1 refused to call 911 and to be sent out to the hospital.

The Department verified all incident reports (LIC624) submitted regarding R1 for the following date of incidents: 2/24/2026, 1/31/2026, 12/23/2025, 12/20/2025, 12/16/2025, 12/14/2025, 11/22/2025. Based on the review, the Department confirmed that the reports were not received.

LPA discussed with Administrator, that the facility must submit incident reports for "Any incident which threatens the welfare, safety or health of any resident ". LPA noted that R1 is a resident who is over the age of 90 and any fall for this resident, is considered an incident that threatens his/her health and safety. LPA noted to ADM that progress note 12/20/2025, notes that R1 has sustained a skin tear about 2 inches wide. LPA noted 3 days later, on 12/23/2025, R1 had sustained another fall and it was observed his/her old skin tear was bleeding. LPA advised ADM to ensure, moving forward, any incident incident which threatens the welfare, safety or health of any resident, is reported to the Department of Social Services Community Care Licensing. LPA advised if facility staff is unsure if an incident needs to be reported, they can contact LPA Manuel Monter or contact the San Jose Regional office and speak to the desk duty officer of the day for clarification. ADM agreed and understood.

Reappraisals

During complaint investigation, it was R1 has auditory and visual impairment. R1 is non ambulatory and uses a walker. R1 is able to bath, dress him/herself. R1 is able to care for his/her own toileting needs. R1 is able to store and administer his/her own medications as per his/her Physician’s report, dated March 8, 2025. Page 2 Out of 4

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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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