435202874-3-18-2026-26-AS-RMAO-DSGT8G-20260324143019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 03/18/2026
Date Signed: 03/18/2026 04:27:41 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
10/21/2025 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20251021105638

FACILITY NAME:	IVY PARK AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	PADILLA SANCHEZ, KENIA		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 39	DATE:	03/18/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Karen Nickolai		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility did not provide assistance with dressing in a timely manner.
Facility did not provide food service.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Karen Nickolai.

On 10/21/2025, the Department received a complaint with the allegations that facility did not provide assistance with dressing in a timely manner and facility did not provide food service.

On 10/30/2025, the Department conducted an initial investigation visit. LPA interviewed ED, 7 staff, and 4 residents.

LPA observed all residents of the memory care unit were in activity room.

Continue on lIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

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 3

Control Number 26-AS-20251021105638

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: 03/18/2026

NARRATIVE

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Facility did not provide assistance with dressing in a timely manner:
Facility did not provide food service:
The allegations are that the facility did not provide assistance with addressing in a timely manner and facility did not provide food service.

On 10/19/2025, RP alleged that food service of Memory Care Unit residents were not provided assists with dressing in a timely manner and their breakfast service were delayed.

On 10/30/2025, LPA interviewed Executive Director (ED) Karen Nickolai. ED stated that on 10/19/2025, 3 caregivers and 1 medication technician in AM shift called out for work. There was only 1 caregiver who reported to work. There were 32 residents in care. ED stated he/she pulled 5 staff from food service and housekeeping service departments to assist residents with wake up dressing service and breakfast service.

ED stated there were family members from 3 residents visited the facility on 10/19/2025 morning, they also assisted the residents with dressing service and breakfast service at that time period.

ED stated residents were dressed up in the morning on 10/19/2025 and breakfast were served to residents, even though some delay for breakfast.

On 10/30/2025, LPA interviewed Executive Cook (S1). S1 confirmed he/she and Maintenance Director (MD), 2 housekeepers, and a dishwasher were pulled to assist residents for wake up dressing service and breakfast service on 10/19/2025 morning.

LPA interviewed 6 staff. 6 Out of 6 staff stated morning shift staff assist residents with their morning routine including dressing and breakfast services. 6 Out of 6 staff stated they did not hear any resident was left in the room without breakfast due to neglect.

LPA interviewed 7 residents. 3 Out 7 residents stated they walk to dining room for meals and they do not have any complaints against the facility. 4 Out of 7 residents were unable to answer questions due to cognitive disorder.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20251021105638

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: 03/18/2026

NARRATIVE

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Based on the interview, on 10/19/2025 morning, there were 3 caregivers and 1 medication technician called out for work, ED pulled 5 staff from housekeeping department and food service department to assist residents for dressing in the morning and breakfast service. The residents were assisted with dressing and were brought to dining room, and breakfast were served to residents on 10/19/2025.

There is no evidence of neglect found on the incident of 10/19/2025 morning.

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview was conducted with ED. This report was provided to review and for signature. A copy of this report was provided to ED.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3