435202744-9-29-2026-26-AS-RMAO-DYS48C-20261011185231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 09/25/2026
Date Signed: 09/29/2026 02:33:56 PM

Unfounded

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
09/25/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260925095955

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:	DATE:	09/25/2026
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Administrator Kellie Shearer		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not prevent an altercation between residents

INVESTIGATION FINDINGS:

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(This complaint investigation report is being amended to add an additional interview that was inadvertently not in the report.) Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint investigation visit and met with Administrator Kellie Shearer

On September 25, 2026, the Department received a complaint alleding Staff did not prevent an altercation between residents.

On September 14, 2026, the Department received a report regarding resident R1 and R2. The report stated the following, On September 12, 2026 around 7:36am, R1 walked up to R2 when he/she was in the dining room and hit him/her on the head. No injuries noted. Staff S1 intervened and separated the two residents.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

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 3

Control Number 26-AS-20260925095955

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: 09/25/2026

NARRATIVE

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On September 18, 2026, Licensing Program Analyst (LPA) Manuel Monter interviewed Regional Health Services Specialist (RHSS) Sharisse Toves. RHSS stated that resident R1 reported that R1 struck resident (R2) in the dining room and S1 intervened and separated the residents. RHSS stated there is no ongoing conflict between R1 and R2. R2 reported that the strike hurt but declined to go to the hospital. RHSS stated there were no visible or apparent injuries. According to R2, R1 walked by and slapped him/her without any verbal interaction.

On September 25, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1. S1 stated on September 12, 2026, R2 sat down on table 16, which is directly across from the kitchen. S1 stated he/she had assisted R2 with his/her order and returned to the kitchen to get the prepared plates of food. S1 stated as he/she was exiting the kitchen, he/she could see R1 approach R2. S1 stated he/she saw R1 tugging at R2, telling him/she to move and claimed that table was his/her. S1 stated when he/she observed this, he/she put the plates down and walk toward them, to intervene. S1 stated as he/she approached he/she saw R1 with a closed fist hit R2 in the side of the head with a slapping motion. S1 stated R1 was able to make 3 consecutive hits before he was able to separate both residents. S1 stated R1 has not exhibited these aggressive behaviors before.

On September 25, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1-R3. R1 stated he/she did not recall the event that occurred at the dinning area. R1 stated he/she did not want to speak to LPA because he/she did not recall. R1 was unable to provide relevant information regarding the allegation and LPA thanked R1 for his/her time.

Resident R2 stated he/she does recall the incident on September 12, 2026. R2 stated that morning, he/she sat down on the table and dinning staff had helped him/her with his/her order. R2 stated about a minute or so after, R1 approached him/her. R2 stated, R1 had told him/her that the table he/she was sitting at, was his/her table and to move. R2 stated he/she didn't want to move. R2 confirmed that R1 wasn't yelling, only tugging at his/her shirt insisting he/she move. R2 then stated he/she told R1 that he/she wasn't moving, then R1 had hit him/her in the head 3 times. R2 stated staff immediately intervened and stopped R1 from hitting him/her. R2 stated S1 redirected R1 to another table on the other side of the dinning area. R2 stated he/she was not struck again by R1 that day or any day after, or anytime before this incident.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20260925095955

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: 09/25/2026

NARRATIVE

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(This complaint investigation report is being amended to add an additional interview that was inadvertently not in the report.)

Licensing Program Analyst Manuel Monter interviewed resident R3. R3 stated he/she does have some brief recollection of the incident between R1 and R2, in the dinning area that morning on September 12, 2026. R3 stated he/she only recalls that something happened and Staff S1 got in between R1 and R2 and walked R1 to the other side of the dining area. R3 stated he/she doesn’t recall anything else about this incident, only that something happened, and S1 got in-between R1 and R2.

The Department reviewed Resident R1's Progress notes from September 25, 2026- July 10, 2026. Based on a review, there is no documented incident prior to September 12, 2026, where R1 exhibited aggressive behaviors towards other residents.

The Department reviewed Resident R1's Service Plan dated August 18, 2026. Under cognitive / orientation, the service plan states R1 has mild cognitive impairment. Under interventions, the plan states staff will offer redirection as needed.

Based on investigation, the incident on September 12, 2026, was an isolated incident, wherin resident R1 was upset that resident R2 sat at a table he/she wanted to sit at (Located in the assisted living dinning area on the first floor) and had struck R2, out of the blue and without warning. Both residents did not sustain an injury. Staff S1 intervened immediately the moment he/she heard R1 pestering R2 and was able to intervene when R1 had struck R2.

The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

LIC9099 (FAS) - (06/04)

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