435202847-7-26-2026-26-AS-RMAO-DXY2LQ-20260915172955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 07/24/2026
Date Signed: 07/26/2026 11:06:57 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
02/16/2026 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20260216134721

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	BALDUGO, VALERIE		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 119	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Karina Nevarez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident wandering away from facility.
Staff did not properly conduct pre-admissions assessment for resident.
Staff did not follow resident's dietary plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez and stated the purpose of the visit.

On 02/16/2026, the Department received a complaint with the above allegations. On 2/18/2026, 03/05/2026, 06/05/2026, 06/29/2026 and 07/08/2026 LPA Partoza interviewed staff, collected and reviewed documents and inspected the facility.

See LIC 809C
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

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-20260216134721

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/24/2026

NARRATIVE

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Facility staff did not provide adequate supervision resulting in resident wandering away from the facility.

Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated R1 wandered from the facility building on two occasions after admission. RP further stated facility staff notified the family by telephone regarding the reported incidents and expressed concern that written incident reports were not provided. RP also stated R1’s behaviors changed after admission and expressed concern that R1 required Memory Care services.

On 02/18/2026, 03/05/2026, 06/05/2026, and 06/29/2026, LPA interviewed seven staff (S1, S2, S3, S4, S5, S6, and S7). Five out of seven staff (S1, S2, S5, S6, and S7) stated R1 exhibited wandering or exit-seeking behaviors after admission. Six out of seven staff (S1, S2, S3, S5, S6, and S7) stated R1 wore an elopement bracelet. Five out of seven staff (S1, S2, S5, S6, and S7) stated staff located and redirected R1. Four out of seven staff (S2, S3, S5, and S6) stated R1’s condition changed after admission and additional supervision or Memory Care placement was discussed. S7 stated R1 was observed in the facility parking lot and did not recall R1 leaving the facility grounds.

On 02/18/2026 and 06/29/2026, LPA observed designated exit doors equipped with an elopement alarm system. S9 demonstrated the operation of the alarm system. LPA observed the alarm activate when an elopement bracelet approached a designated exit.

LPA reviewed progress notes and resident records. Progress notes documented R1 exhibited wandering and exit-seeking behaviors after admission. Progress notes documented implementation of an elopement bracelet, redirection, increased supervision, hourly monitoring, reassessments of care needs, and communication with the responsible party regarding changes in R1’s condition. Progress notes documented R1 was redirected while on facility property. Progress notes further documented the responsible party reported R1 had not wandered or left home alone prior to admission.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20260216134721

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/24/2026

NARRATIVE

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Facility staff did not properly conduct a pre-admission assessment for resident.

Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated facility staff did not disclose to the family during the admission process that the facility’s Memory Care unit was full. RP further stated S2 and S6 did not meet with the family to discuss the Resident Individualized Service Plan and S6 was not present during the Admission Agreement signing meeting. RP also stated the LIC 603 Pre-Admission Appraisal was provided by facility staff and signed by a family member on 10/23/2025 after the Admission Agreement was signed on 10/21/2025. RP stated the Resident Individualized Service Plan and Cost of Care Communication were marked “Draft” and expressed concern that the facility did not reassess R1 after changes in R1’s behavior.

On 02/18/2026, 03/05/2026, 06/05/2026, 06/29/2026, and 07/08/2026, LPA interviewed seven staff (S1, S2, S3, S4, S5, S6, and S8). Two out of seven staff (S1 and S2) stated the pre-admission assessment was completed using the information available before admission. Four out of seven staff (S1, S2, S4, and S8) stated the family requested or toured Assisted Living and did not request Memory Care placement before admission. Two out of seven staff (S1 and S2) stated the family did not disclose wandering behaviors or concerns that R1 required a higher level of care before admission. Three out of seven staff (S2, S3, and S5) stated the facility’s Memory Care unit had no vacancy when Memory Care placement was discussed. Three out of seven staff (S2, S3, and S5) stated the facility discussed increased supervision, companion care, or alternative Memory Care placement with the responsible party after R1’s condition changed. S8 stated the Admission Agreement and Cost of Care Communication were completed during the admission process.

During a follow-up interview conducted on 07/08/2026, S2 stated the facility’s Memory Care unit had no vacancy when R1 was admitted and the responsible party agreed to Assisted Living placement until a vacancy became available. S2 stated the facility later offered transfer to two sister communities with Memory Care, offered to waive move-in costs and pay moving expenses, and the responsible party declined the transfer because the Memory Care rate was higher. S2 further stated the facility requested one-to-one companion care due to R1’s increased wandering and inappropriate behaviors.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20260216134721

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/24/2026

NARRATIVE

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LPA reviewed the Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Pre-Admission Assessment, Resident Assessment, LIC 603 Pre-Admission Appraisal, Admission Agreement, Resident Individualized Service Plan, Cost of Care Communication, progress notes, and correspondence exchanged between the responsible party and the facility. The Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Pre-Admission Assessment, Resident Assessment, and LIC 603 Pre-Admission Appraisal documented the information available before admission and did not document wandering behaviors, exit-seeking behaviors, or a need for Memory Care placement before admission.

Progress notes documented changes in R1’s condition after admission, implementation of an elopement bracelet, reassessments of care needs, increased supervision, communication with the responsible party, discussion of companion care, and discussion of alternative Memory Care placement. Progress notes dated 12/11/2025 documented the responsible party declined transfer to another Memory Care community because the monthly rate exceeded the family’s price range and requested referrals for companion care agencies. Progress notes dated 12/20/2025 documented the responsible party agreed with the recommendation for 24-hour companion care.

Facility staff did not follow the resident’s physician-ordered dietary plan.

Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated the facility did not follow the physician-ordered diabetic diet identified on the Physician’s Report (LIC 602). RP further stated the family observed R1 consuming desserts and other foods the family believed were not consistent with a diabetic diet. RP also stated the physician-ordered diabetic diet was not reflected on the Resident Individualized Service Plan.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20260216134721

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/24/2026

NARRATIVE

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On 02/18/2026, 03/05/2026, 06/05/2026, and 06/29/2026, LPA interviewed five staff (S1, S2, S3, S5, and S6). One out of five staff (S5) stated physician-ordered dietary information was communicated to dietary staff and meals were prepared according to physician orders. One out of five staff (S5) stated alternate meal choices were available when residents declined the offered meal. Two out of five staff (S5 and S6) provided information regarding R1’s meal service and dietary supervision. S5 stated residents were encouraged, but not forced, to follow physician-ordered diets. S6 stated R1 was encouraged to eat meals in the dining room where staff could provide supervision. S6 further stated staff removed individual coffee creamers from R1’s access after observing that R1 collected and consumed the creamers.

On 03/05/2026 and 06/29/2026, LPA observed the facility kitchen, pantry, refrigerator, freezer, posted menu, and meal service. LPA observed dietary information identifying residents requiring physician-ordered diets was available to dietary staff for meal preparation. LPA observed residents were offered meal choices consisting of protein, carbohydrate, vegetable, and dessert options. LPA observed food inventory maintained for meal preparation.

LPA reviewed the Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Dietary Information Sheet, Resident Individualized Service Plan, medication records, progress notes, facility menu, and the facility’s Diabetes Culinary Program. The Physician’s Report (LIC 602) documented a physician-ordered diabetic diet. The Dietary Information Sheet documented physician-ordered dietary information was communicated to dietary staff for meal preparation. The Diabetes Culinary Program documented procedures for preparing meals for residents requiring diabetic diets, including diabetic-friendly meal options, substitutions, sugar-free desserts, and communication of physician-ordered dietary information to dietary staff. The Diabetes Culinary Program also documented residents may choose their own food selections.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20260216134721

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 07/24/2026

NARRATIVE

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Based on interviews conducted, observations made, and records reviewed, progress notes documented changes in R1’s condition after admission, reassessments of care needs, increased supervision, implementation of additional interventions, and communication with the responsible party. Admission records documented a pre-admission assessment was completed for R1 using the information available before admission. The Dietary Information Sheet documented physician-ordered dietary information was communicated to dietary staff for meal preparation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations are unsubstantiated.

No deficiencies were cited based on the California Code of Regulations, Title 22.

An exit interview was conducted with Executive Director/Administrator (ED/ADM) and a copy of the report was provided.

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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