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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 09/16/2026
Date Signed: 09/16/2026 04:12:39 PM

Document Has Been Signed on 09/16/2026 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR/
DIRECTOR:		MEGHIAN GEULFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 225CENSUS: 218DATE:
09/16/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Regional Health Services Specialist Sharisse TovesTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On September 16, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Regional Health Services Specialist Sharisse Toves and explained the purpose of the visit.

On August 19, 2026, Licensing Program Analyst Manuel Monter was informed by staff S1 that resident R1 had eloped from the facility on August 18, 2026 at around 10:10pm. S1 stated R1 became upset after he/she had not invited to a familial event. S1 stated R2 initially believed that R1 was still at the facility gym at that time around 10:00pm. S1 stated R1’s son/daughter went downstairs to walk a dog and believed he/she saw R1 exit through the front door. S1 stated he/she became aware around 10:10 PM that R1 eloped. S1 stated when he/she was informed that R1 had eloped, staff were looking all over the entire facility. S1 stated when they couldn’t find R1, they contacted 911 around 10:50pm. S1 stated at the same time, it was reported that someone matching R1’s description was found by the great mall. S1 stated R1 was brought back to the facility around 11:00pm. No injuries noted on R1.

S1 stated R1’s partner, R2, went on vacation about 3 weeks ago. S1 stated when R2 was on vacation, S1 observed R1 showing signs of confusion. S1 stated on one occasion, he/she observed R1 sitting on a bench near the dinning room elevator. S1 stated he/she asked R1 what he/she was doing. R1 responded he/she didn’t know where he/she was and was lost. S1 acknowledged that he/she should have given R1 a re-assessment, after viewing these behaviors. S1 stated R1 was allowed to leave the facility unassisted based on the physician’s report. LPA reviewed R1’s physician’s report, which indicated R1 cannot leave the facility unassisted. LPA showed S1 and S1 stated the facility must have misread it. Page 1 Out of 4.
Romeo Manzano
Manuel Monter
DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/16/2026
NARRATIVE
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On August 19, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2-S4. S2 stated he/she is familiar with R1 and described him/her as mostly independent. S2 stated R1 has a neurocognitive disorder. S2 stated she usually sees R1 two to three times per day when he/she is on shift. S2 stated he/she has not observed any changes in R1’s behavior. S3 stated R1 is independent. S3 stated he/she sees R1 2x per week. S3 stated he/she has not observed any changes in behaviors regarding R1. S4 stated R1 has a neurocognitive disorder and typically keeps to him/herself and R2. S4 stated he/she has not observed any concerning behaviors from R1 and stated that, as far as he/she had seen, R1 did not demonstrate behavioral issues.

S4 stated on August 18, 2026, at around 10:15 PM, S1 informed him/her that R1 had eloped. S4 stated R1’s son/daughter was present and explained what had occurred. S4 stated he/she, S1, and family members searched the entire building and surrounding area. S4 stated R1 was located at approximately 11:00 PM by local law enforcement, following reports of an individual near the Great Mall area. S4 stated R1 was transported back to the facility, where he/she observed him/her and did not note any injuries.

On August 19, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1 and R2. LPA asked R1 what occurred on August 18, 2026. R1 stated he/she doesn’t recall what happened yesterday. R1 stated he/she only recalls that he/she went for a walk that lasted 45 minutes. R1 stated he/she doesn’t actually know what time he/she left the facility. R1 stated he/she does remember that he/she was lost yesterday and it was dark. R1 stated because it was dark, he/she had difficulty finding his/her way back. R1 stated he/she doesn’t remember interacting with the police.

R2 stated his/her son/daughter was present at the time of the elopement. R2 stated he/she and his/her son/daughter were watching a television show (“Ted Lasso”), and R1 became tired of waiting and told them he/she was going out for a walk. R2 stated R1 sometimes goes downstairs to the gym to use the elliptical machine, and he/she did not check to confirm where he/she went. R2 stated R1 left the building. R2 stated R1 was fine when he/she returned to the facility and that he/she told R1 that he/she could not leave the facility unassisted.

Page 2 Out of 4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/16/2026 04:12 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/16/2026 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT MILPITAS
FACILITY NUMBER: 435202744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2026
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services …to meet their needs.

This requirement was not met as evidence by:
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ADM stated that she will provide a written plan of action outlining how she will ensure that residents residing in the assisted living side of the facility, who cannot leave the facility unassisted, have their supervision needs are being met.
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Based on interviews & records reviewed, on August 18, 2026, resident R1 eloped from the facility unassisted. R1’s physician’s report dated 4/27/2026 states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 was found by law enforcement 0.8 miles away from the facility.
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ADM stated she will submit the plan of action to LPA by POC due date September 17, 2026.
Type B
09/23/2026
Section Cited
CCR87463(a)

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87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. This requirement is not met as evidenced by:
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ADM stated she will submit a written plan of action on how she will ensure residents care plans are updated in writing as frequently as necessary to note significant changes, and to keep the appraisal accurate. ADM stated she will submit the plan of action to LPA by POC due date September 23, 2026.
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Based on record review, R1’s care plan dated May 30, 2026, did not address the fact that R1 could not leave the facility unassisted, as per R1’s Physician’s Report dated April 27, 2026. S1 indicated that he/she had observed R1 exhibiting signs of confusion and appearing lost.
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S1 stated he/she should have given R1 a re-assessment, after viewing these behaviors. S1 acknowledged it was a mistake on his/her part. This poses/posed a potential health, safety or personal rights risk to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/16/2026
NARRATIVE
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On August 24, 2026, the Department received an Incident Report (IR) regarding resident R1. The IR stated on August 18, 2026, at 10:10pm, assisted living resident with neurocognitive disorder, walked out of the front door without his/her watch or cell phone. At 10:10pm it was reported that R1 wasn't found. At 10:50pm, 911 was called. Coincidentally a report was made to police that someone fitting the description appeared confused and lost at the Great Mall. Police approached R1 and was brought back by police officers at 11:10pm.

On August 26, 2026, Licensing Program Analyst Manuel Monter interviewed staff S5-S15. 4 out of 11 staff (S5, S6, S7, S12 ) stated they are not aware of R1’s behaviors or anything of note regarding R1. 5 Out of 11 staff (S8, S9, S10, S11, S15) stated they have not had any interactions with R1.

S13 stated during his/her shift, he/she administers medication to R1. S13 stated when he/she is administering medications, he/she has noted R1 will forget that he/she is supposed to take the medication. S13 stated when he/she knocks R1’s apartment door to give R1 his/her medication, he/she can hear R2 tell R1 to open the door. S13 stated after R1 opens the door, he/she will go into the apartment, towards the bedroom. S13 stated R2 will remind R1 that he/she needs to go back and meet with S13, because he/she is there to administer his/her medications. S13 stated he/she has given R1 his/her medications, and R1 will not take the medication until he/she has been prompted to take the medication. S13 stated R1 will be given medication on hand and a glass of water. S13 stated he/she has to tell R1 every step to take the medication. S13 clarified that sometimes R1 does sometime know what to do.

S13 also noted during that time R2 was not at the facility, he/she has observed R1 in the hallway lost. S13 stated he/she observed R1 on the second floor seated on one of the seats. S13 stated she asked R1 what he was doing. R1 stated he didn’t know. S13 stated he/she assisted R1 back to his/her bedroom.

S14 stated R1 is very forgetful. S14 stated R1 has come to his/her work area asking for things, as if they were a store, appearing confused. S14 stated he/she does remember times when R1 has asked him/her for directions- like where the dinning hall is or the elevators are. S14 stated R1 was being serious and appeared confused and was not joking. S14 stated he/she couldn’t note any specifics regarding dates when these events took place. Page 3 Out ot 4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/16/2026
NARRATIVE
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The Department reviewed R1’s Physician’s Report, dated April 27, 2026 states R1 has major Neurocognitive disorder. Page 6 states R1 would be at risk if allowed to leave the community unsupervised due to neurocognitive disorder. The Department Reviewed Resident R1’s Needs and Services Plan, dated May 30, 2026, states R1 is able to leave community independently.

The Department Reviewed R1’s Progress Notes, dated August 18, 2026. The note states R1, with neurocognitive disorder, walked out of the front door without his/her watch or cell phone. R2 assumed R1 would go to the gym but when he/she went to the gym, R1 wasn’t there. R2 couldn’t find R1. R1’s son/daughter assisted in searching and called staff to report at 10:10pm. Staff searched the building and the surrounding area. At 10:50pm, 911 was called and coincidently a report was made that someone fitting the description appeared confused and lost at the great mall. Local Law enforcement brought back R1 back to the facility at 11:10pm. Based on a search on google maps, the location between Ivy Park Milpitas and the Great Mall is approximately 0.8 miles.

On August 26, 2026, a case management was conducted and the facility was cited a Type A deficiency under the code section, 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4). The facility was also issued an immediate civil penalty of $500 for absence of supervision, for an elopement that occurred on August 6, 2026.

On July 20, 2026, a case management was conducted and the facility was cited a Type B deficiency under the code section,  87463 Reappraisals (a).

As a result, the Department issued an immediate civil penalty of $1,000 for a repeat violation the absence of supervision, which resulted in R1 eloping from the facility.
The Department will also issue an immediate civil penalty of $250 for a repeat violation, under code section  87463 Reappraisals (a).

Deficiency cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Regional Health Services Specialist Sharisse Toves and a copy of the report was provided. Appeal Rights was provided. Page 4 Out of 4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC809 (FAS) - (06/04)
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