435202874-1-28-2026-26-AS-CKAI-DTCT9L-20260421143206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 01/28/2026
Date Signed: 01/28/2026 05:07:30 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
09/24/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20250924091243

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: 35	DATE:	01/28/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility does not provide blankets for resident
Facility does not make medical appointments to address resident's change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Karen Nickolai, Administrator (ADM). On 09/24/2025, the department received a complaint with the above allegations. On 09/25/2025, LPA Marrufo conducted an initial complaint investigation visit. On 11/06/2025, LPA Marrufo conducted an additional complaint investigation visit.

Allegation: Facility does not provide blankets for resident - Unfounded

When the department received the complaint, it was alleged that the facility was not providing a blanket for resident R1’s bed.

See LIC9099-C pages for more information. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
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 3

Control Number 26-AS-20250924091243

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

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During visit on 09/25/2025, LPA Marrufo observed R1’s bed and observed it to be covered with a bedsheet and a blanket along with an absorbent pad on the pillow and another absorbent pad on the bed.

On 11/06/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement. Section I.A.1.c states, “Furnishings. We encourage You to furnish your Apartment with your own furniture. If You are unable to provide your own furniture or You choose not to provide it, Ivy Park will provide You with furniture for an extra fee.”

On 01/28/2026, LPA Marrufo obtained a copy of R1’s Optional Inventory of Personal Property. The line “I do not wish to inventory personal property” was initialed.

During interview on 01/28/2026, R1’s Responsible Person stated that it was R1’s family’s responsibility to provide blankets for R1.

During visit on 01/28/2026, LPA Marrufo interviewed staff S1-S3. Staff S1-S3 stated that family members of residents are responsible for providing blankets for their admitted family members.

During visit on 01/28/2026, LPA Marrufo interviewed ADM. During interview, ADM stated families are responsible for providing blankets to their resident.

Allegation: Facility does not make medical appointments to address resident's change in condition - Unfounded

When the department received the complaint, it was alleged that the facility did not make medical appointments for R1 after R1 was observed to experience a change in condition that resulted in R1 having difficulty swallowing.

During visit on 01/28/2026, LPA Marrufo obtained two Physician’s Reports for R1. One Physician’s Report was dated 02/10/2025 and indicated that R1 did have a special diet. R1’s second Physician’s Report, which was dated 02/14/2025, indicated that R1 did not have a special diet.

Page 2 of 3.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
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 3

Control Number 26-AS-20250924091243

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

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During visit on 11/06/2025, LPA Marrufo obtained Hospital Discharge Notes and Physician’s Fax Reports.

A Hospital Discharge Note dated 06/19/2025 states, “Diet: Solids Soft & Bite-Sized…Liquids Mildly Thick…Medications crushed with puree...Supervision 1 to 1…Feed by: staff for patient safety”

A Hospital Discharge Note dated 08/22/2025 states, “Diet: Regular soft and bite-sized with mildly thick liquids.”

A Physician’s Fax Report that was sent by the facility to R1’s physician on 07/25/2025 states, “The above mentioned resident is on mechanical diet and crushing medications. We are updating our system and require periodic update. Please provide with signature otherwise please advise.”

This agency has investigated the complaint allegations listed. Based on interviews, review of records, and observations, the department has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

This report was reviewed with Administrator Karen Nikolai and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
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)

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