435202874-4-22-2026-26-AS-CKAI-DU3MC9-20260514092907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 04/22/2026
Date Signed: 04/22/2026 04:18:18 PM

Unsubstantiated

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
04/11/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250411110434

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: 36	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Executive Director (ED) Karen Nickolai		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not change resident timely
Resident missed medication
Due to neglect, resident sustained a pressure injury
Staff did not follow physician's orders
Staff do not meet resident's feeding needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit.

On 4/11/2025 the Department received a complaint with the above allegations.

On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7).

On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed Reporting Party (RP). RP states a resident, referred to as R1, was not changed in timely manner.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250411110434

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: 04/22/2026

NARRATIVE

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RP states R1 was left in soiled diapers for 12 hours on four occasions in April 2025. RP states these incidents were observed by a Private Caregiver (PCG) for R1. RP states he/she is unable to verify these incidents with the caregiver agency.

On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7). 6 Out 7 staff state he/she changes residents every two hours. S6 states he/she observed a resident soiled on one occasion and reported the incident to facility management. S6 did not provide additional information regarding this incident.

The Department interviewed 7 Residents (R1 to S7). 6 Out of 7 residents state he/she does not need assistance with toileting. R1 did not respond to questions due to neurocognitive impairment.

Review of R1’s Preplacement Appraisal Information dated 7/16/2024, under Services Needed, ‘No’ is selected for toileting, and ‘YES’ selected for incontinence, ‘needs depends’ signed by RP and facility management.

On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information.

Resident missed medication

On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated the facility did not follow R1’s medications orders, resulting in R1 not receiving his/her medications. RP did not provide additional information regarding these incidents.

On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 6 Out of 7 staff state he/she is not aware of any issues with residents not receiving medications. S4 states he/she observed one medication error and reported it to facility management. S4 did not provide additional information regarding this incident.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20250411110434

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: 04/22/2026

NARRATIVE

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The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with receiving his/her medications. R1 did not respond to questions due to neurocognitive disorder.

Review of R1’s Medication Administration Record (MAR) for February 2025, medications were administered per doctor’s orders and no discrepancies were observed.

On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage.

Due to neglect, resident sustained a pressure injury
On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated R1 sustained a pressure injury, ulcer in April 2025 due to staff not changing R1 in a timely manner. RP did not provide additional information regarding the pressure injury, ‘ulcer.’

On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7). 6 Out 7 staff state he/she changes residents every two hours. S5 states he/she has not observed residents who were neglected at any time. S6 states he/she observed a resident soiled on one occasion and reported the incident to facility management. S6 did not provide additional information regarding this incident.

The Department interviewed 7 Residents (S1 to S7). 6 Out of 7 residents state he/she does not need assistance with toileting. R3 states if he/she did need toileting assistance, staff will help him/her. R1 did not respond to questions due to neurocognitive impairment.

LPA Tarin reviewed facility incident reports submitted to the Department for April 2025 and no noted incidents of any resident sustaining a pressure injury ‘ulcer’ while in care were observed.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20250411110434

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: 04/22/2026

NARRATIVE

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On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage.
Staff did not follow physician's orders
On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated the facility did not follow R1’s medications orders, resulting in R1 not receiving his/her medications. RP did not provide additional information regarding these incidents.

On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 6 Out of 7 staff state he/she is not aware of any issues with residents not receiving medications. S4 states he/she observed one medication error and reported it to facility management. S4 did not provide additional information regarding this incident.

The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with receiving his/her medications. R1 did not respond to questions due to neurocognitive disorder.

Review of R1’s Medication Administration Record (MAR) for February 2025, all medications were administered per doctor’s orders and no discrepancies were observed.

On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information.

Staff do not meet resident's feeding needs

On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated he/she ‘believes’ R1’s weight loss in November 2024 was due to staff not providing assistance with eating.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20250411110434

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: 04/22/2026

NARRATIVE

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On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 7 Out of 7 staff stated he/she provides feeding assistance to residents.

The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with eating. R3 and R4 stated he/she has observed staff providing feeding assistance to residents. R1 did not respond to questions due to neurocognitive disorder.

Review of R1’s Preplacement Appraisal Information dated 7/16/2024, under Services Needed, ‘No’ is selected for help with eating.’ Review of R1’s Change of Condition dated 11/14/2024, R1 is noted to not have a history of significant weight loss or weight gain. R1’s Meal Consumption Level of Assistance notes R1 to need ‘dining moderate assist, CM to cue resident throughout meals and snacks.”

On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED, and a copy of this report was provided.

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END OF REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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