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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202874
Report Date: 04/09/2026
Date Signed: 04/09/2026 05:23:18 PM

Document Has Been Signed on 04/09/2026 05:23 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 SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR/
DIRECTOR:		NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 82CENSUS: 39DATE:
04/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Karen NickolaiTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Karen Nickolai. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. There was no obstruction to block the walkways. The staff area of the facility was also inspected. LPA tested the delayed egresses in the facility. When tested the delayed egresses emitted a loud sound, which continued to ring until staff reset the alarm.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms.

Fire extinguisher was serviced in April 16, 2025. The facility was equipped with smoke and carbon monoxide detectors. The Facility's Sprinkler System was last inspected on March 27, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 27, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on April 9, 2026.

During todays visit, LPA requested a copy of the following residents death certificates (DR1-DR4). LPA also requested information regarding DR2-DR4's diagnosis.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2026
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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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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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 SAN TOMAS
FACILITY NUMBER: 435202874
VISIT DATE: 04/09/2026
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LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA noted during medication audit/Review, that residents R1, R2 and R3 had medications that were not listed on the centrally stored medication record. Resident R1 did not have his/her medication M1 (fill date March 5, 2026) listed on his/her centrally stored medication record. Resident R2 did not have the following medications listed on his/her centrally stored medication record: M2 (fill date 3/4/2026), M3 (Fill date 11/11/2025), M4 (Fill date 12/24/2025), M5 (Fill date 12/24/2025). Resident R3 did not have the following medications listed on his/her centrally stored medication record: M6 (Expiration date October 2026), M7 (fill date 12/31/2025), M8 (Fill date 12/31/2025), M9 (fill date 3/28/2026) , M10 (Fill date 12/12/2025), & M11 (Fill date October 3, 2025).

LPA showed the discrepancies to the health services director Kyleigh Whitely. No documentation was provided by health services director Kyleigh Whitely to LPA, to verify that the medications in question were included in each corresponding centrally stored medication record.

A deficiency and technical violations are being cited during today's visit. This report was reviewed with Administrator Karen Nickolai and a copy of the signed report was provided. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2026 05:23 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/09/2026 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN TOMAS
FACILITY NUMBER: 435202874

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. LPA noted R1, R2 and R3 had medications that were not listed on the centrally stored medication record. LPA showed the discrepancy to the health services director Kyleigh Whitely but no documentation was provided to verify that the medications in question were included in each corresponding centrally stored medication record. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2026
Plan of Correction
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ADM stated her plan of correction will be to conduct a training, on how to centrally store medications. ADM stated she will send training documenation to LPA by POC due date. ADM stated she will send the plan of correction to LPA by POC due date, April 16, 2026
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


LIC809 (FAS) - (06/04)
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