435202874-5-26-2026-26-AS-CKAI-DUV299-20260608171133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 05/26/2026
Date Signed: 05/26/2026 04:01:26 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
02/09/2026 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20260209115931

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:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Executive Director (ED) Karen Nickolai		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility did not reassess resident after resident experienced a change in health condition.

INVESTIGATION FINDINGS:

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

On 2/09/2026 the Department received a complaint with the above allegation.

On 2/09/2026 and 2/19/2026 the Department interviewed the Reporting Party (RP). RP stated a resident, referred to as R1, had a fall on 10/27/2025 while in care at the facility, which resulted in R1 being hospitalized. RP stated the facility did not assess R1 after being accepted back into the facility after being hospitalized.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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-20260209115931

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: 05/26/2026

NARRATIVE

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On 2/19/2026, the Department conducted the initial complaint investigation visit and requested pertinent documentation. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated residents are assessed after having a fall.

On 5/26/2026 the Department interviewed Executive Director (ED) Karen Nickolai. ED stated R1 fell on 10/26/2025 and was hospitalized. ED stated R1 did not return to the facility after the fall on 10/26/2025. ED stated a 30 days notice was given for R1 on 10/28/2025.

Review of R1's care notes, R1 fell on 10/26/2025 and was sent out to the hospital.

Review of medical documentation dated 10/26/2025, R1's physician notes that R1 requires a '24/7 caregiver in place', "need of higher level of care."

Review of Resident Charges/Payments Ledger for R1, notes 'Notice Given: 10/28/2025, Notice For: 11/28/2025.'

On 5/26/2026, the Department conducted an additional interview with RP. RP stated R1 did not return to the facility after falling on 10/27/2025 due to R1 needing a higher level of care. RP stated R1's "needs exceeded Ivy Park."

Although the allegation may have happened or is 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 Executive Director (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: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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