435202744-7-20-2026-26-AS-RMAO-DWGU8A-20260730152110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 07/20/2026
Date Signed: 07/20/2026 02:05:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251110154451

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

ALLEGATION(S):

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Facility staff neglected resident in care resulting in resident sustaining injuries

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Manuel Monter and Simi Rai conducted an unannounced complaint inspection/investigation to deliver the findings on the above allegations. LPAs met with Administrator, Meghian Guel and stated the purpose of today's visit.

On November 10, 2025, the Department received a complaint alleging facility staff neglected resident in care resulting in resident sustaining injuries.

Based on investigation, on November 13, 2025, and April 28, 2026, the Department interviewed a witness (referred as W1). W1 stated resident (referred as R1) was a resident of the facility for 2 years. W1 stated he/she is aware of R1’s history of fall incidents wherein it’s been reported R1 having at least 5 falls in the last 3 years.

Continuation on LIC 9099-C, Page 1 of 5.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

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 5

Control Number 26-AS-20251110154451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 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.

Based on investigation, records reviewed, and interviews conducted, R1 was generally independent with his/her ADLs with limited assistance; however, R1 had mobility limitations and was identified as being at risk for falls which resulted R1 sustaining injuries from falls. The Department was unable to establish whether the alleged neglect due to lack of care and supervision did nor did not contribute to R1’s injuries. Therefore, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Exit interview was conducted with Administrator, Meghian Geul and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 26-AS-20251110154451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Page 2 of 5.

W1 stated R1 was independent and known for not calling for assistance, by not utilizing his/her call button. On 11/9/2025, R1 was taken at the hospital because R1 had an unwitnessed fall in his/her bedroom. W1 stated that R1 sustained injuries on his/her face, neck and extremities reported by the hospital/medical skilled professional.

W1 stated R1 had a recurring sore on R1’s right shin due to poor circulation. W1 also added that R1 was on blood thinning medications that made him/her susceptible to bruising. W1 stated it was normal for R1 to have bruises on his/her legs due to “very poor circulation in his/her legs.”

W1 stated two weeks prior to 11/9/2025, R1 was trying to open a drawer from under the sink when the door popped open and “got him/her in the face.” Based on review of residents’ medical and facility records, there was no report that the said incident occurred or that R1 sustained an injury to his/her face. Moreover, W1 stated R1 was always hitting his/her legs on the couch, table, bed post, and toilet that caused bruising due to his/her right foot amputation which affected his/her mobility or ambulation.

Based on review of R1’s physician’s report dated May 19, 2025, R1 was visually and auditory impaired and required physical assistance with bathing but was otherwise independent. R1 used a walker due to right foot amputation, was considered non-ambulatory due to his/her physical condition and could not leave the facility unassisted.

In April, May and June 2026, the Department interviewed 7 staff (referred as S1-S7). Based on interviews, S1 stated that although he/she had limited interactions with R1 and 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.

S2 stated that R1 required assistance for showering; however, he/she was otherwise independent. S2 stated R1 used a walker and was considered at risk for falls. S1 reported that he/she was not present at the facility on 11/9/25, when R1 fell, and was not aware of the incident.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20251110154451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Page 4 of 5.

During investigation interview with S6, the Department showed S6 the alert charting notes for R1, which documented that R1 had fallen and hit his/her head on 11/08/2025. S6 stated that he/she was still new to working at Ivy Park at the time of the incident. S6 stated that he/she was aware of one fall that occurred earlier in the day and that he/she contacted R1’s responsible party about the incident. S6 stated R1 indicated he/she was okay following the incident and that another staff (S2) was also present at the time. S6 acknowledged that he/she could have followed up with the Resident Care Coordinator (RCC) regarding the incident but failed to do so and was unable to provide a reason. S6 stated that he/she did not recall observing any bruising on R1’s face, neck or extremities, explaining that the incident occurred a long time ago and he/she could not remember.

S7 stated that he/she was not familiar with R1 and had never met him/her. The Department informed S7 that R1 was a resident of assisted living (AL) who required assistance with showering, and had sustained multiple falls, on 10/23/2025, and additional falls on 11/08/2025, and 11/09/2025. S7 stated that no staff member reported these incidents to him/her, had he/she been notified, he/she would have arranged for R1 to be sent to the hospital sooner. S7 added that staff did not consult with him/her or request that he/she conduct a re-assessment of R1 following the falls.

The Department reviewed R1’s Charting Notes (CN) with the following noted observations:
· On 6/29/25 R1 sustained a fall.
· On 8/21/25, 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 10/23/25, 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 10/24/25, 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 11/8/25, staff and W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a staff. S6 assessed R1, who stated he/she had hit his/her forehead.
· On 11/9/25, around 5:00pm, R1 was found on the floor.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20251110154451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Page 3 of 5.

S3 stated that R1 was hard of hearing and required assistance with laundry and showering. S3 further stated that R1 was ambulatory and used a walker for mobility. S3 reported that he/she was not working on 11/9/25 and was therefore not aware of R1’s fall on that date. S1 stated that he/she did not recall being informed about the two falls reportedly occurred on 11/8/25. S1 further stated that he/she did not recall observing any bruising on R1’s face or extremities on 11/09/2025.

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.

S4 was asked about R1’s other falls reportedly on 06/28/2025, 08/21/2025, and 10/23/2025; however, S4 stated he/she had no knowledge of these incidents and was unable to provide information regarding the falls. S4 recalled seeing a bruise on R1’s chin and neck but did not recall the date. S4 believed the fall occurred prior to R1’s hospitalization and described R1 as having a large and dark purple discoloration. S4 stated did not recall whether the bruise was documented [in R1’s facility chart].

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 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 was unable to recall the exact date of the incident but stated that R1 was observed in the morning after the fall. S6 stated that R1’s family was present during the evening, and after the family left, R1 appeared to be “okay”. S6 reported that R1 later stated that he/she tripped on his/her carpet and fell, landing on his/her face. S6 stated he/she did not observe any bruising on R1’s face or neck following that fall.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

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