435202744-9-23-2026-26-AS-RMAO-DYS2D8-20261011171752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 09/23/2026
Date Signed: 09/23/2026 05:00:55 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
03/30/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260330122635

FACILITY NAME:	IVY PARK AT MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	MEGHIAN GEUL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS: 224	DATE:	09/23/2026
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Interim Administrator Kellie Shearer		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff lack of supervision leading a memory care resident hit another two residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Interim Administrator Kellie Shearer

On July 30, 2026, the Department received a complaint alleging that a memory care resident hit another two residents in care due to neglect/lack of supervision by facility staff.

On April 8, 2026, the Department received an unusual incident report (LIC624) to report altercation between two residents (referred as R1-R3) on March 13, 2026. The facility reported on LIC624 that on March 13, 2026, at 2:30am, in the Living Room, R1 hit resident R2. R1 had hit R2 on the back of his/her head with no injury sustained noted on the report. R1 had also put his/her hands around R3’s neck and punched him/her on the bottom left side of the lip. The facility reported this altercation incident to Law Enforcement Agency (LEA). Page 1 Out of 6

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

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

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 26-AS-20260330122635

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 MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 09/23/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On April 8, 2026, Licensing Program Analyst Steve Chang conducted investigation interviews with two residents involved in the altercation (R2 and R3), however, R2 and R3 were unable to provide relevant information, nor unable to provide a response pertaining to the incident that occurred on March 13, 2026, due to their neurocognitive disorder.

On April 8, 2026, Licensing Program Analyst(LPA) Steve Chang conducted investigation interview with staff (referred as S1). LPA asked S1 if he/she was present at the facility when the incident occurred between 3 residents in the memory care unit. S1 confirmed he/she was working NOC shift on March 13, 2026. S1 stated resident (R2) went out from his/her room ( located in the corridor which rooms 124-141) to the living room of memory care unit . R2 was heading to the living room area wherein resident (R1) was behind R2, also headed to the common area. S1 stated he/she witnessed R1 punching R2 on the back of his/her neck three times.

S1 stated he/she and staff S2 were in the living room of memory care unit. S1 stated he/she and S2 immediately intervened and separated R1 and R2. S1 stated R1 punched R2 suddenly and rapidly, and they (S1 and S2) did not have sufficient time to intervene but were able to prevent further altercation attempts by R1. S1 and S2 separated, observed or monitored both residents. Both involved residents were assessed with no injuries noted.

S1 stated, during interview, after he/she put R2 back to his/her bed (after the altercation between R1 and R2, the same night) , he/she walked back to the living room and met resident R3 in the hallway. R3 told him/her that someone entered his/her room and choked him/her. S1 and R3 went back to R3's room but did not find anyone inside the room. S1 stated that prior to proceeding to the living room with R3; S1 had assessed R3 for possible injuries wherein redness on R3’s neck and a bruise on the side of his/her lips was visible. S1 escorted R3 to the living room and as they passed by the dining room; they saw R1 in dining room. R3 told S1 that the person whom he/she saw in dining room (R1) is the person who entered in his/her room and choked him/her.

Page 2 Out of 6.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20260330122635

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 MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 09/23/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On May 22, 2026, Licensing Program Analysts (LPAs) Manuel Monter and Steve Chang conducted a random interviewed with staff S4-S6. S4 stated R1 and R2 had no prior interactions or any form of relationship before the incident on March 13, 2026. S4 stated the incident on March 13, 2026 was the first time R1 hit R2 or R3. S4 stated resident R1 has hit other residents in the past. Staff S5 and S6 stated R1, R2 and R3 do not have a negative relationship with each other and have not interacted with each other much. S5 and S6 acknowledged that resident R1 has the behavior of physical aggression such as hitting staff and residents prior to the incident that occurred on March 13, 2026.

On June 16 and 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1, S2 to clarify their previous interview statements, and with new staff, S7. S1 stated moments before the incident between R1 and R2, he/she was standing in the living room, near the Memory Care Directors Office while S2 was in the living room. S1 stated R2 was seen walking in from the direction of his/her bedroom towards the living room. S1 stated he/she saw R2 was he/she was entering the living room. S1 stated as R2 was entering the living room, he/she was stuck 3 times in the neck by R1, with a closed fist. S1 stated it was quick and the entire altercation happened in less than 5 seconds.

S1 stated regarding the incident between R1 and R3: as he/she was walking back to the living room (after escorting R2 to his/her room- immediately after the altercation between R1 and R2), that is when he/she observed resident R3 in the hallway and he/she told him/her that someone had chocked him/her. S1 stated R3 insisted that he/she was chocked and punched in the face. S1 stated he/she checked R3’s neck and observed redness. S1 stated she also checked R3’s face and observed a bruise on R3’s lip.

S1 stated that both NOC shift staff are responsible for supervising all residents during the night. S1 explained that the facility has resident groupings and that on the night in question, S2 was assigned to R1. S1 stated that when R1 does not sleep, R1 will wander through the memory care unit and enter other residents’ bedrooms. S1 reported that R1 gets up at night approximately two to three times per week. S1 stated that when R1 is awake and wandering, staff ensure that R1 is redirected either back to his/her bedroom or to the living room area for supervision. S1 stated he/she is aware of one or two instances in which R1 has hit other residents, but he/she could not recall when these incidents occurred.

Page 3 Out of 6

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20260330122635

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 MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 09/23/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S1 stated the previous memory care director told the staff to keep close monitoring of R1. S1 stated staff needs to keep an eye on R1, keeping a line of sight on R1 if he/she is awake during the NOC shift, and redirect if he/she is trying to enter another residents bedroom. S1 stated during the NOC shift, there is only 2 staff.

S2 stated he/she could not remember whether he/she was working when the altercations between R1 and R2 or R1 and R3 occurred. LPA informed S2 that, according to the staff schedule for March, he/she was working the NOC shift on March 13, 2026. S2 stated that it had been many months and he/she did not recall the events. When asked about R1’s behaviors, S2 stated that LPA could speak with staff assigned to the memory care unit for more information.

S2 stated that during the NOC shift, staff in the memory care unit are responsible for checking on residents every two hours, including R1. S2 stated that at times staff are unaware of R1’s exact location. S2 reported that if R1 is not in his/her room, he/she may be inside another resident’s bedroom. S2 stated he/she does not know how often R1 wanders into other residents’ rooms. S2 stated that if R1 enters another resident’s room, staff will redirect him/her back to his/her room. S2 also stated that if staff see R1 walking or wandering in the hallways, they assist him/her either back to his/her room or to the living room area.

S7 stated that R1’s behaviors are generally calm when interacting with him/her. S7 reported hearing other caregivers mention or complain that R1 was aggressive. S7 stated that while working the night shift, he/she observed R1 attempting to enter other residents’ bedrooms, noting that R1 tried to do this almost every night. S7 explained that staff are expected to redirect R1 from entering other residents’ rooms. S7 stated that he/she would remain in the common areas to monitor R1’s movements. S7 added that staff are aware R1 will attempt to enter other residents’ rooms nightly and that during the NOC shift, it is audible when R1 is entering or attempting to enter another resident’s room. S7 stated he/she had heard reports of R1 hitting other residents and staff but does not know the specific details.

On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed S8 and S9. S8 stated R1 would attempt to enter other residents’ rooms, and staff redirected him/her from the apartments. S8 stated staff redirect him/her if he/she tries to enter other rooms. S8 stated staff know when he/she attempts to enter rooms because he/she walks around the hallways and knocks before entering. Page 4 Out of 6

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 26-AS-20260330122635

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 MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 09/23/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S9 stated R1 would wander into random resident rooms, sleep in other residents’ beds, and use other residents’ toilets. S9 stated that when R1 entered another resident’s room, staff would redirect him/her. S9 stated staff became aware of these incidents if they observed R1 entering the room, if the resident residing in the room informed staff, or if staff heard noise coming from the room. S9 stated R1 entered resident rooms more frequently during nighttime hours.

On July 24, 2026, Licensing Program Analyst Manuel Monter interviewed staff S3. S3 stated he/she does have a faint recollection of the incident that occurred on March 13, 2026, with residents: R1-R3. S3 stated he/she was informed there was an incident in the memory care unit and he/she went over there right away. S3 stated he/she did not see the altercation between these residents. S3 stated he/she saw R2 had dried blood next to his/her temple and was sleepy. S3 stated he/she could not recall on which side of the face. S3 stated he/she also checked on resident R3. S3 stated he/she was informed by a care giver, that R1 was in resident R3’s room and R1 had stuck/chocked him/she. S3 stated he/she checked R3’s face and neck. S3 stated he/she doesn’t think he/she saw anything on resident R3’s neck. S3 stated he/she did observe some slight discoloration on resident R3’s lip. S3 stated it may have also been some general discoloration.

S3 stated resident R1 can be very aggressive. S3 stated R1 didn’t listen to everybody. S3 stated R1 would also have the behavior of wandering and going into other residents bedrooms. S3 stated if R1 tries to enter another residents bedroom, staff will go and redirect him/her to either his/her bedroom or the common area. S3 stated he/she knows R1 is attempting to enter a residents bedroom because the memory care unit is quiet. S3 stated, from the entrance of the memory care unit as you enter, Resident R1’s bedroom is on the right side. S3 stated residents R2 and R3’s bedrooms are on the left side.

The Department reviewed R1’s service plan dated February 2, 2026. Under cognitive / orientation, R1 demonstrates poor judgement and is potentially disruptive and dangerous to self and others. The care team supports R1 with orientation, redirection and wayfinding. Under wandering and elopement, the service plan states R1 wanders into apartments agitating other residents. The care team provides redirection when R1 is wandering. Under Behavioral Expression, the service plan states that R1 expresses behaviors that require staff intervention. R1 expresses behaviors of disturbed sleep. R1 wakes up on some nights but is easily redirected back to bed. Page 5 Out of 6

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20260330122635

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 MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 09/23/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On August 29, 2025, the Department received an incident report regarding R1. The incident report stated on August 29, 2025, at approximately 12:30am, R1 was observed in resident R4’s bathroom. Shortly after, R4 entered his/her bathroom, at which point R1 returned and struck R4. Care staff immediately intervened, separating both residents. No visible injuries were noted on either resident at the time of incident.

The Department reviewed R1’s Progress Notes.
Progress note Dated August 29, 2025: Around 12:30am, R1 was going into other residents rooms. R1 went into room 103 and used both 103A and 103B toothbrushes to brush his/her teeth. R4 was in the bathroom after R1 left his/her room. R1 went back in and had hit R4, staff intervened and redirected R1. R4 was ok with no injuries noted.

Progress Note dated: September 25, 2025: 6:02am, R1 went into resident room 114 and woke up resident. Resident called a care giver to have R1 leave the room, but once R1 was out of the room he/she was pounding on the doors trying to get in.

Progress Note dated October 6, 2025: 11:00am, R1 was seen by family member of 115B, that R1 sat on his/her bed and was hugging/kissing him/her on the neck while he/she was sleeping. Care staff was made aware immediately and took care of situation.

Progress Note Dated, January 3, 2026: R1 was in another residents room, staff made multiple attempts to redirect, which resulted in R1 being physically aggressive.

Based on the investigation, it was confirmed that an altercation occurred between R1 and R2 on March 13, 2026. Interviews indicated that Staff S1 and S2 intervened immediately when the incident began. Shortly after R1 and R2 were separated, Resident R3 informed staff that R1 had struck and choked him/her in his/her bedroom. Following the investigation, there was not a preponderance of evidence to conclude that staff neglect or lack of supervision resulted in R1 striking Residents R2 and R3.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 6 Out of 6.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 5 of 6