435202874-6-26-2025-26-AS-MPAA-DKRSAA-20250821134157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 06/26/2025
Date Signed: 06/26/2025 02:41:00 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
05/15/2025 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20250515114342

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: 25	DATE:	06/26/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jessica Pryor		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not provide adequate supervision to residents in care.
Staff are under the influence of alcohol and drugs while caring for residents.
Staff are mismanaging residents' medications.
Administrator is not present on facility premises for sufficient number of hours.

INVESTIGATION FINDINGS:

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On 6/26/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Regional Operations Specialist (ROS), Jessica Pryor and explained the purpose of the visit.

Regarding the allegation of Staff do not provide adequate supervision to residents in care, Reporting Party (RP) stated that there has been many incidents of falls and residents passing away and NOC (night) shift employees disappearances.

LPA Donato interviewed seven responsible parties. F1 mentioned that it is a nice, new facility and all the staff members are very kind and pleasant. There are many daily activities that R1 participates in and really enjoys the constant music and conversations. Overall, F1 is happy with the staff and how friendly and caring they are.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

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-20250515114342

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: 06/26/2025

NARRATIVE

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The chef is amazing and always makes sure R1 likes what he/she is eating. F2 believes that R2 is being well taken care of. F3 shared that a private caregiver found R3 on the floor shaking and the facility called the paramedics and sent R3 to the ER. No video footage was available to review what happened or if R3 hit his/her head. F3 also mentioned that R4 is doing well, S5 has been great and seems to be well liked by family members of the other residents. They also love the head chef and activities director. F7 shared that the last few times they visited, they only had one caregiver on the floor who couldn’t leave, and the resident (R7) had to go to the bathroom.

LPA also interviewed five staff members. S1 mentioned that he/she is not overwhelmed with work, its just enough. S3 and S4 shared that staff help each other out. However, S2 mentioned that An extra person will help a lot and they won’t feel so rushed if there is 4 people, S5 shared that there is not enough help during their shift. According to the ROS, there have since been an additional 6 staff members who were added to the roster, 3 of which are care staff and the other 3 are Licensed Nurses. When staff calls out, the facility calls for agency for coverage.

LPA attempted to interview five residents but due to neuro cognitive disorder, they are not able to give answers.

Regarding the allegation of Staff are under the influence of alcohol and drugs while caring for residents, RP stated that The Med Technicians are using substances narcotics and drinking alcoholic beverages and going to work like that.

During the interviews, four staff members (S1, S2, S3, S4) shared that they haven’t seen any staff come in who are under the influence of drugs or alcohol. S5 did not answer the question.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250515114342

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: 06/26/2025

NARRATIVE

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Regarding the allegations that Staff are mismanaging residents' medications. RP stated that Medication is not being given in a timely manner and is not being justified on the proper dosage being given as negligence.

Based on records review, LPA reviewed 5 resident records. All medications are accounted for and given on the scheduled time.

Regarding the allegation of Administrator (ADM) is not present on facility premises for sufficient number of hours, RP stated that the administrator does not run this facility correctly and in fact is never present at the facility to oversee anything that goes on there.

During the staff interviews, S1 & S4 mentioned that every time that they are on shift the ADM is in the facility. S2 also shared that ADM is in the facility when he/she is working. S3 said that ADM is here every day.

Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC9099 (FAS) - (06/04)

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