435202874-5-15-2026-26-AS-CKAI-DUUURS-20260608154914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 05/15/2026
Date Signed: 05/15/2026 04:46:00 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
11/05/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20251105115156

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: 38	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Maribel Abinsay		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not ensure resident's feeding needs were met

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Maribel Abinsay. On 11/05/2025, the department received a complaint with the above allegations. On 11/06/2025, LPA Marrufo conducted an initial complaint investigation visit. On 05/14/2026, LPA Marrufo conducted an additional complaint investigation visit.

When the department received the complaint, it was alleged that facility staff were not feeding resident R1.

On 11/06/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement, which was signed on 07/17/2025.

See LIC9099-C page for more information. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

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 5

Control Number 26-AS-20251105115156

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: 05/15/2026

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 11/06/2025, LPA Marrufo obtained a copy of R1’s Physician’s Report, which has an exam date of 07/16/2025. R1’s Physician’s Report stated R1 did not have a special diet. The Functional Capabilities section of R1’s Physician’s Report left the box next to “Unable to Feed Self” unchecked.

On 11/06/2025, LPA Marrufo obtained a copy of R1’s Individualized Service Plan, dated 07/19/2025. The Eating section states, “No assistance required with eating. Resident will eat independently.” The Tray Service section states, “Resident does not require or request tray service. Resident attends meals independently.” The Dietary section states, “Regular menu; no special diet required. Resident eats a normal diet.” The Escorting section states, “Can walk to dining room and all activities within the facility, may need occasional reminder and/or escort. [Resident] maintains ability to attend meals and activities of choice.”

On 11/06/2025, LPA Marrufo interviewed staff S1-S4. During interviews, S1-S4 stated they had regularly fed R1 and never neglected to feed R1.

On 03/27/2026, LPA Marrufo conducted an interview with R1’s Family Member, FM1. During interview, FM1 stated staff regularly fed R1 and never neglected to feed R1.

On 05/15/2026, LPA Marrufo conducted a telephone interview with Administrator (ADM) Karen Nickolai. During interview, she stated staff regularly fed R1 and never neglected to feed R1.

On 05/15/2026, LPA Marrufo conducted a telephone interview with R1’s family member, FM2. During interview, FM2 stated R1 would call FM2 daily and ask FM2 to send R1 food. FM2 stated he/she was not sure if the facility neglected to feed R1 because FM2 was not always at the facility.

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

This report was reviewed with Maribel Abinsay and a copy of this report was provided.

Page 2 of 2. END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
11/05/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20251105115156

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: 38	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not ensure resident's hygiene needs were met

INVESTIGATION FINDINGS:

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

When the department received the complaint, it was alleged that R1 had a foul body odor and staff would become upset when asked to shower R1.

The Functional Capabilities section of R1’s Physician’s Report has the box next to “Unable to Bathe Self” unchecked. The boxes next to “Unable to Dress/Groom Self” and “Unable to Care for Own Toileting Needs” are unchecked.

The Grooming section of R1’s Individual Service Plan states, “No assistance required with personal grooming. Can groom independently. Resident will groom independently.”

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20251105115156

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: 05/15/2026

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

Based on information from interviews and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Maribel Abinsay 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: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 26-AS-20251105115156

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: 05/15/2026

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

The Bathing section of R1’s Individualized Service Plan states, “Requires stand-by assistance for all showering/bathing needs (1-2x/week). Maintains independence, and is clean, neat and odor free. Set up and stand-by for shower or bath.”

The Dressing section of R1’s Individual Service Plan states, “No assistance required with dressing needs. Resident will dress independently.”

During interviews on 11/06/2025, S1-S4 stated staff did not neglect R1’s hygiene needs and staff maintained R1’s shower schedule. S2 stated R1 needed assistance with showering, but R1 would sometimes shower himself/herself. S2 stated R1 would sometimes dress in two to three layers of clothes and staff would offer to help change R1, but R1 would refuse staff help. S3 stated staff applied lotion and deodorant on R1. S3 stated he/she never noticed R1 having bad body odor. S4 stated R1 would ask staff for extra showers in addition to R1’s shower schedule and S4 would assist R1 with showering outside his/her usual shower schedule.

During interview on 03/27/2026, FM1 stated staff showered R1 every other day. FM1 stated he/she wanted staff to shower R1 daily, but staff told FM1 that R1’s agreement stated staff were to shower R1 every other day. FM1 stated staff did not neglect to meet R1’s hygiene needs. FM1 stated FM1 did not know if R1 had a foul body odor.

During interview on 05/15/2026, ADM Nickolai stated staff regularly showered R1 and never neglected R1’s hygiene needs. ADM Nickolai stated she never observed R1 to have foul body odor.

During interview on 05/15/2026, FM2 stated to have visited R1 every other day. FM2 stated he/she would often observe R1 with a foul body odor. FM2 stated R1 smelled like he/she had a soiled diaper. FM2 stated he/she attempted to take R1 out of the facility for lunch, but R1 had foul body odor. FM2 stated he/she would request staff to shower R1 and sometimes staff would assist with showering R1 and sometimes they would not.

Page 2 of 3.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5