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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 09/23/2026
Date Signed: 09/23/2026 05:09:34 PM

Document Has Been Signed on 09/23/2026 05:09 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: 223DATE:
09/23/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Interim Administrator Kellie ShearerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On September 23, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1 and to clear deficiencies cited on September 16, 2026. LPA met with Interim Administrator Kellie Shearer and explained the purpose of the visit.

Clearing Plan of corrections for deficiencies cited on September 16, 2026.

The facility was cited the following Type A and Type B deficiencies on September 16, 2026
  • 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4), POC due date September 17, 2026.
  • 87463 Reappraisals (a), POC due date, September 23, 2026.
LPA received plan of corrections for Type A and Type B deficiency by POC due date. Deficiencies cleared during todays visit. POC cleared letter provided to ADM

Elopement: September 11, 2026.

On September 11, 2026, Licensing Program Analyst Manuel Monter was informed via email from Administrator Meghian Geul, stating resident R1 eloped from the memory care unit, on September 11, 2026. R1 had climbed over the fence in the memory care unit and left the community around 8:32am. Staff reported R1 missing at 9am. R1 was found at his/her family member's house at 2:30pm. R1 had walked into his/her Family member’s (FM) house, and R1's FM called the facility inform them he/she was there.
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Romeo Manzano
Manuel Monter
DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 09/23/2026
NARRATIVE
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 ADM stated R1 was assessed by staff at the FM's house, and the ambulance took R1 to Santa Clara Kaiser to be evaluated. Based on a google maps search: the distance between FM’s home and Ivy Park Milpitas is approximately 8.5 miles.

On September 16, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1. S1 stated he/she wasn’t at the facility on September 11, 2026 when the elopement occurred. S1 stated he/she received a phone call from the Resident Care Coordinator (RCC) who stated he/she had arrived at the facility at around 9am and was informed that R1 couldn’t be found. S1 stated once he/she was informed, he/she contacted local law enforcement and informed the FM. S1 stated R1 was found around 2:30pm at FM’s home. S1 stated when video footage was reviewed, it was discovered that R1 had eloped from the facility by using a grey planter box, which he/she got on top of, to get over the fence.

S1 stated days prior, the facility was doing an assessment with the previous Health Services Director, (HSD). S1 stated it was decided that they would reduce R1’s 1 on 1 companion from 24 hours a day to 12 hours a day. S1 stated it would be from 11:00am-11:00pm. S1 stated this change occurred on September 9, 2026. LPA asked S1- when R1 does not have a 1 on 1 care giver, who is responsible for his/her care / supervision. S1 stated the care staff would be responsible for keeping an eye on R1 / keeping a line of sight on R1. S1 stated if R1 is in the living room, someone should be in the room with him/her. S1 stated if R1 is wandering around the memory care unit, staff should keep a line of sight on R1.

On September 18, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2-S6. S2 stated on September 11, 2026, he/she had last observed R1 at 8:14am, in the common area. S2 stated it was time for breakfast and he/she went to provide Ensure to residents at breakfast. S2 was then informed that care givers were unable to locate R1.

S3 stated he/she prepared breakfast (Breakfast served at 8:30am) and, once residents were brought into the dining room, the caregiver assigned to R1 stated he/she was looking for R1 and could not locate him/her. The caregiver had checked all areas but was unable to find R1.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
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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: 09/23/2026
NARRATIVE
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S4 stated that R1 was in the activity section completing a puzzle around 8:10 a.m. S4 stated he/she had assisted another resident to the restroom and afterward asked where R1 was. S4 stated he/she asked caregivers if they had seen R1 and searched the entire area but could not locate him/her.

S5 stated he/she finished assisting his/her grouping tasks at approximately 8:20 or 8:30 a.m. S5 stated that while staff were preparing residents for the dining room and accounting for everyone, they noticed that R1 was not present. S5 stated he/she was busy assisting residents in the dining room at that time, and the Medtech began searching for R1.

S6 stated he/she was getting his/her residents ready and then brought them to the common area. S6 stated he/she went to assist another resident and he/she saw the Medtech rushing down the hallway looking for R1. He/she then joined staff in searching for R1. S6 stated the last time he/she saw R1 was at approximately 8:10 to 8:20 a.m, in the charting room.

S6 stated he/she wanted to report a prior incident that occurred a few weeks earlier, though he/she could not recall the exact date. S6 stated he/she was in Room 111 with a resident. S6 stated when he/she looked outside the window, she observed R1 attempting to use a chair as a ladder to climb. S6 staff redirected R1 and this incident was reported.

The Department reviewed R1’s Service Plan, dated September 1, 2026. The service plan states, under cognitive / orientation: R1 has severe impairment… and is potentially disruptive and dangerous to self and/or others. Under Wandering and elopement: R1 wanders throughout the building, exit seeking during the day. Under intervention, staff providing curing and redirection as needed.

The Department reviewed R1’s Physician’s Report, dated August 2, 2026. The physician report states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 also lacks hazard awareness.

The Department reviewed resident R1's Progress Notes:
Progress Note Dated August 21, 2026 states, R1 presented with new behavior. While in guidance of his/her private care giver, he/she was outside in the courtyard and dragged a chair to the fence, stood on it and attempted to climb over the fence. R1 was redirected. Page 3 Out of 4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
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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: 09/23/2026
NARRATIVE
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Progress note dated September 11, 2026 states, at around 7am, R1 was administered his/her scheduled medications by medtech in the activity area. R1 was seated and working on puzzles. At approximately 8:14am, R1 was administered his/her scheduled 8am medication and he/she remained in the activity area. At around 8:30am, the med tech observed the R1 wandering around. Medtech redirected the resident to the charting area. Medtech then went to the medication room. When medtech went out to the charting, the resident was no longer there. Breakfast service was beginning and no door alarms had been activated. While in the dinning area a care giver informed that he/she is looking for R1 because he/she is not in the common area, dinning room and/or his/her room. Staff began searching all residents bedrooms. R1 could not be located. Staff began searching the facility and immediate area. At 2:38pm, medtech received word that R1 was found at FM’s home.

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 September 16, 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 $1000 for absence of supervision, for a repeat violation the absence of supervision.

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 on September 11, 2026.

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

This report was reviewed with Interim Administrator Kellie Shearer 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: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2026 05:09 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/23/2026 at 04:22 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: 09/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2026
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 she will submit a Plan of Correction outlining how she will ensure that residents who cannot leave the facility unassisted, have their supervision needs are being met. ADM stated R1 now has 1 on 1 care giver 24 hours a day.
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Based on interviews & records reviewed, on September 11, 2026, resident R1 eloped from the facility unassisted. R1’s physician’s report dated 08/02/26 states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 was found approximately 8.5 miles from the facility.
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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: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
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