435202847-8-8-2025-26-AS-RMAO-DKX4TU-20250826192340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 08/08/2025
Date Signed: 08/08/2025 02:05:21 PM

Unfounded

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
05/13/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250513093103

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	NEVAREZ, KARINA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 103	DATE:	08/08/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Val Baldugo-Macasieb		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing assistance to resident as necessary.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Val Baldugo-Macasieb.

On 05/13/2025, the Department received the complaint. On 05/20/2025, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include 3 resident’s physician’s report, service plans, long term care insurance paperwork and 1 resident’s admission agreement.

It was alleged by the reporting party (RP) that the staff are not providing assistance in filing a resident’s (R1) long-term care insurance as necessary as the facility continually failed to provide the required documentation to R1’s long-term care (LTC) company resulting in a delayed reimbursement for R1. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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 3

Control Number 26-AS-20250513093103

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 SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 08/08/2025

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

The review of records showed that the LTC insurance company has sent a letter to R1/R1’s responsible party advising of not receiving certain documents on 01/21/2025 and 05/02/2025. In the letter dated 05/02/2025 that was sent to R1's responsible party's address, it states that on 04/09/2025, 05/18/2025, and 05/27/2025 the LTC company requested but did not receive certain information in order to continue processing the claim.

On 05/15/2025, the RP states that facility acted upon the issue and reached out to R1’s LTC insurance.

2 staff members (S1 – S2) were interviewed. S1 started his/her position in mid-February 2025 and S2 started his/her new position in late February – early March 2025.

Based on interview, S1 stated that typically the facility would be informed by the resident’s responsible party if the LTC insurance company is missing forms, as the LTC insurance company communicates directly with the resident and/or responsible party.

S1 and S2 states that they were only informed that R1’s LTC insurance company was missing forms on 05/13/2025 by R1’s responsible party. S1 and S2 denied being informed in March or April, that R1’s LTC insurance company was missing forms. S1 stated to have only received an email from R1’s responsible party regarding issues with the LTC insurance on two occasions, which was on 05/13/25 and sometime last year.

It was stated that upon receiving the email from R1’s responsible party on 05/13/2025, the facility immediately sent the required form to the LTC insurance company and followed up with the LTC insurance company as well to confirm receipt.

Based on interview, 2 out of 2 staff members thought it was the facility’s responsibility to submit all forms to the resident’s LTC insurance companies.

Page 2 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250513093103

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 SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 08/08/2025

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

Upon following up with the facility’s regulatory team on 05/20/2025, S1 confirmed that it is actually not the facility’s responsibility to submit the forms to the LTC insurance company. It was stated that facility was filing the resident’s LTC insurance as courtesy to the resident, as this service is not indicated in their admission agreement or included in service plan. It was stated that the facility will continue to assist in filling out necessary forms such as the care needs assessments and monthly residence form, however it is the resident or resident’s responsible party to submit all necessary forms to the LTC insurance afterwards.

8 staff members who were interviewed all denied R1’s care ever stopping despite issues with R1’s LTC insurance. 8 out of 8 staff stated that R1 was always provided assistance with care.

Based on review of R1’s admission agreement and service plan, the service of the facility filing R1’s LTC insurance is not written in the admission agreement or service plan. As per the RP, the service of filing R1’s LTC insurance was offered as from a discussion when R1 first moved in.

On 08/08/2025, the facility's process when it comes to residents LTC insurance is to continue to work with the resident and/or resident's responsible party on completing forms required by the facility to fill out. However, the resident and/or resident's responsible party's is now responsible in sending the paperwork(s) to the LTC insurance.
The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Val Baldugo-Macasieb and a copy of the report was provided.

Page 3 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3