<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 01/28/2026
Date Signed: 01/28/2026 11:09:25 AM

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
10/13/2025 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20251013112243
FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 33DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director (ED) Karen NickolaiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced investigation visit to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit.

On 10/13/2025 the Department received a complaint with the above allegation.

On 10/16/2025, the Department conducted a complaint investigation visit, and interviewed the Executive Director (ED), 5 Staff (S1 to S5) and 4 Residents (R1 to R4). LPA requested pertinent documentation to include but not limited to staff schedules, Medication Administration Records (MARs) and resident physician's reports.

It has been alleged staff did not administer medication as prescribed sometime in October 2025.

Page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
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 2
Control Number 26-AS-20251013112243
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 TOMAS
FACILITY NUMBER: 435202874
VISIT DATE: 01/28/2026
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
On 10/16/2025 and 1/28/2026 the Department interviewed Executive Director (ED). ED states she is not aware of staff not administering residents medications as prescribed at any time in October 2025.

On 10/16/2025 the Department interviewed 6 Staff (S1 to S6). 4 Out of 6 staff state he/she administers resident's medications as prescribed. 4 Out 6 staff state he/she is not aware of staff not administering resident's medications as prescribed. S1 did not provide additional information. S4 states he/she does not assist with medications.

On 10/16/2025 the Department interviewed 4 Residents (R1 to R4). 2 Out of 4 resident state he/she receives his/her medications. S3 state he/she does not need assistance with medication. S4 declined to be interviewed.

The Department conducted a medication audit, reviewing 5 random resident's Medication Administration Records (MARs) and medication bottles with S2 and S3. A discrepancy was observed on 1 resident's MAR. A pill count was conducted, and the resident's medication bubble package was reviewed. The resident's medication was administered as prescribed, but it not was noted on the MAR.

This agency has investigated the complaint alleging staff did not administer medication as prescribed. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with ED and a copy of this report was provided.

Page 2 of 2

END OF REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2