435202847-9-21-2026-26-AS-RMAO-DYS2MA-20261011173048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 05/28/2026
Date Signed: 09/21/2026 04:21:29 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
02/07/2026 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20260207105309

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: 118	DATE:	05/28/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Karina Nevarez		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

2 - Staff do not respond to residents call buttons for assistance in a timely manner.
5 - Facility has staff shortages resulting in delay in delivering residents' ADLs

INVESTIGATION FINDINGS:

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

This report is being amended to provide additional information.
Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint visit and met with Executive Director/Administrator (ED) Karina Nevarez. LPA stated the purpose of the visit.

On 02/07/2026, the Department received a complaint with the above allegations. LPA conducted visits and interviews on 02/12/2026, 03/05/2026, 04/03/2026, 4/29/2026, 05/05/2026 and 05/28/2026.

Allegation 2: Staff do not respond to residents' call buttons for assistance in a timely manner.
On 02/12/2026 and 03/05/2026, LPA interviewed RP, staff (S1 through S8), and residents R1 through R7 regarding call button response times.

page 1

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

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 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

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This report is being amended based on new information
On 02/12/2026, Licensing Program Analyst (LPA) interviewed Reporting Party (RP), who stated staff do not respond to resident call buttons in a timely manner. RP stated staff should generally respond within approximately 5 to 10 minutes; however, RP alleged residents wait 15 to 20 minutes or longer for assistance. RP stated he/she observed residents waiting extended periods of time for assistance, including approximately 30 minutes to be assisted to bed. RP further stated resident council meeting minutes dated 02/04/2026 reflected resident concerns regarding insufficient caregivers and delays in receiving assistance.

On 02/12/2026 and 03/05/2026, LPA interviewed 8 staff (S1 through S8), and 6 residents (R2 through R7) regarding call button response times. S1 to S8 stated resident call buttons are prioritized and typically responded to within approximately five to ten minutes, depending on resident needs and staff availability.
R3 stated staff generally respond within five to ten minutes; however, there were occasions when response times exceeded twenty minutes. During an interview with R3, LPA conducted a pendant test. R3 activated the pendant multiple times and no staff response was observed for more than twenty minutes. LPA subsequently contacted staff directly. LPA observed staff in the area during the testing period; however, the cause of the delayed response could not be determined. The pendant response test involving R3 was conducted on 03/05/2026. LPA observed no staff response for more than 20 minutes following multiple pendant activations.

LPA conducted additional pendant tests with residents R2, R4, R5, R6, and R7. During those five tests, staff responded within approximately two to five minutes. Residents generally reported receiving assistance when needed and expressed satisfaction with staff response times. Some residents reported occasional delays when staff were assisting other residents. LPA observed one delayed response during testing involving R3. The pendant response test involving R2 was conducted on 04/03/2026 and staff responded within approximately five minutes. Pendant response tests involving R4, R5, R6, and R7 were conducted on 05/28/2026, with staff responses observed within approximately 1.5 to 2 minutes. In total, LPA conducted six pendant response tests on 03/05/2026, 04/03/2026, and 05/28/2026. One test resulted in no staff response for more than 20 minutes, and five tests resulted in staff responses within approximately 1.5 to 5 minutes.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

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This report is being amended based on new information.
Allegation 5: Facility has staff shortages resulting in delay in delivering residents' activities of daily living (ADLs).
On 02/12/2026, 03/03/2026, 04/03/2026 and 05/28/2026, LPA interviewed Reporting Party (RP), staff S1 through S8, and residents R1 through R7 regarding staffing levels and resident care services.The staff interviews referenced above that were identified as occurring on 03/03/2026 were conducted on 03/05/2026.

RP stated the facility was understaffed and alleged residents experienced delays in receiving assistance with activities of daily living.

LPA interviewed eight staff members (S1 through S8). Four staff members (S3, S4, S5, and S7) acknowledged that delays may occur when caregivers are busy, responding to resident needs, or when staffing resources are limited. Three staff members (S5, S7, and S8) acknowledged that employee call-offs, staffing vacancies, and occasional staffing shortages occur. S7 and S8 stated managers and supervisors assist with resident care when staffing shortages occur and help provide coverage for vacant shifts. S6 stated caregivers work together to prioritize resident needs and respond to requests for assistance.

LPA interviewed residents R1, R2, R3, R4, R5, R6, and R7, who required varying levels of assistance with activities of daily living, including bathing, dressing, toileting, transfers, escorting, and assistance with getting into bed. 7 Out of 7 stated staff assisted them with their activities of daily living and provided assistance when needed. 7 out of 7 residents did not report missed showers, missed toileting assistance, missed transfers, delayed assistance with getting into bed, or unmet care needs due to staffing levels. 7 Out of 7 resident stated satisfaction with the care and assistance provided by staff.

Based on interviews and observations, there is not a preponderance of evidence to prove the alleged violation(s) for allegations 2 and 5 did or did not occur; therefore, the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. See LIC 9099A for allegations 1,3 and 4. An exit interview was conducted and a copy of the report was provided to ED/ADM Karina Nevarez.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
02/07/2026 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20260207105309

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: 118	DATE:	05/28/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Karina Nevarez		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1 - Facility did not follow procedure which protect the safety, acceptability and nutritive values of food being served.
3- Facility elevator is in disrepair
4 - Staff are not following the facilities disaster & mass casualty plan

This page is for Allegations # 1, 3 and 4 continued from LIC 9099

INVESTIGATION FINDINGS:

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

This is a continuation of the LIC9099 for allegation, 1, 3 and 4

Allegation 1: Facility did not follow procedures which protect the safety, acceptability, and nutritive values of food being served.

On 02/12/2026, Licensing Program Analyst (LPA) interviewed Reporting Party (RP), who stated concern regarding food safety practices, specifically that room service meals may remain covered and awaiting delivery for approximately 20 to 30 minutes. RP expressed concern that meals may become cold and that food handling practices could affect food safety.

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

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This report is being amended based on new information
LPA interviewed kitchen staff (S1 to S5), and care staff (S6 to S8) 8 out of 8 Staff stated that meals are prepared in the kitchen, covered prior to delivery, and placed in a designated area for pickup by care staff. 8 out of 8 staff stated food trays may occasionally remain awaiting pickup when care staff are assisting residents; however, meals are covered and residents may request food to be reheated in the microwave inside their apartments. Interviews with S1 through S5 regarding food preparation and meal service were conducted on 02/12/2026. Interviews with S6 through S8 regarding meal delivery and resident care were conducted on 03/05/2026

LPA interviewed residents R2, R4, and R5 who routinely receive room service meals. 3 out of 3 residents reported meals were delivered warm, did not report significant delays in meal delivery, and did not express concerns regarding food safety. R4 stated food was delivered three times daily and reported satisfaction with meals. R5 stated meals were delivered warm and reported no concerns regarding food service. R2 stated meals were occasionally delivered to the room, arrived warm, and reported no concerns regarding food service.

LPA observed the dining area during meal service and observed staff wearing gloves while handling food service items and cleaning dining surfaces. LPA observed the kitchen, walk-in refrigerator, freezer, food storage areas, emergency food supplies, and food preparation areas. The kitchen was observed to be organized and sanitary. LPA did not observe evidence of unsafe food handling, food contamination, improper food storage, or conditions adversely affecting the safety, acceptability, or nutritive value of food. On 05/05/2026, LPA interviewed S9 regarding facility cleaning and disinfecting products. S9 stated cleaning and disinfecting products used in the dining and kitchen areas are ordered for facility use and are diluted with the appropriate amount of water according to their intended use.

LPA reviewed 4 out of 4 food handler training records for kitchen and dining staff. LPA verified current California Food Handler certifications for food service personnel responsible for food preparation and meal service.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

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This report is being amended based on new information.
Allegation 3 – Facility elevator in disrepair
On 02/12/2026, Licensing Program Analyst (LPA) interviewed Reporting Party (RP), who stated the elevator located on the right side of the elevator bank had been out of service multiple times during the previous six months. RP stated the elevator was not working on the day the complaint was submitted and alleged elevator outages continued to occur despite prior repairs.

On 02/12/2026, LPA interviewed five staff members (S3, S4, S5, S7, and S8). S3, S4, S5, S7, and S8 stated elevator malfunctions occasionally occurred and maintenance requests were submitted when repairs were needed. S3 stated one elevator was not working on one occasion; however, the second elevator remained operational. S4 stated the elevator malfunction occurred during a prior power outage and maintenance arranged repairs. S5 stated he/she recalled one elevator malfunction occurring approximately July 2025. S7 stated the elevator on the right side was repaired following a malfunction that occurred in approximately December 2024 and estimated repairs took approximately one to two weeks. S8 stated elevator repairs generally took approximately two to three days depending on the availability of replacement parts and stated elevator outages were not prolonged.

On 05/05/2026, LPA interviewed the Maintenance Director (MD/S9), who stated that when an elevator becomes inoperable, the facility contacts the elevator service vendor and repairs are generally initiated within 24 hours. MD/S9 stated that when one elevator is out of service, the second elevator remains operational and residents continue to have access to facility services while repairs are being completed.S9 stated that from January through May 2026, one elevator was out of service on at least one occasion and was returned to service within approximately 24 hours. S9 stated elevator repairs are generally completed within less than 24 hours and not more than two days.

On 02/12/2026, 03/05/2026, 04/03/2026, and 04/29/2026, LPA toured the facility and did not observe an elevator that was inoperable or in disrepair. Interviews and observations conducted during the investigation indicated that elevator malfunctions were addressed through maintenance and repair services, a second elevator remained available when needed, and residents continued to have access to facility services during repair periods.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

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This agency has investigated the complaint alleging the facility did not follow procedures which protect the safety, acceptability, and nutritive values of food being served; the facility elevator was in disrepair; and staff were not following the facility disaster and mass casualty plan. We have found that these allegations were unfounded, meaning that the allegations were false, could not have happened, and/or are without a reasonable basis.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Karina Nevarez and a copy of the report was provided.

page 8
end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC9099 (FAS) - (06/04)

Page: 8 of 8

Control Number 26-AS-20260207105309

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: 05/28/2026

NARRATIVE

1
2
3
4
5
6
7
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14
15
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This report is being amended based on new information

Allegation 4 – Staff are not following the facility disaster and mass casualty plan

On 02/12/2026, Licensing Program Analyst (LPA) interviewed Reporting Party (RP), who stated concern regarding whether the facility was following its disaster and mass casualty plan. RP stated concern regarding emergency preparedness and whether residents were receiving adequate fire and emergency preparedness training.

02/12/2026 and 03/05/2026 LPA interviewed six staff members (S3, S4, S5, S6, S7, and S8), who stated staff receive ongoing training regarding emergency preparedness, including fire safety, earthquake response, evacuation procedures, and disaster response protocols. S3, S4, S5, S6, S7, and S8 stated disaster preparedness and emergency response training are conducted monthly. S4, S5, S6, S7, and S8 stated staff are trained regarding emergency evacuation procedures, emergency exits, resident assistance during emergencies, and use of fire extinguishers. S7 and S8 stated the facility maintains emergency water supplies, emergency food supplies, emergency equipment, evacuation devices, and resident emergency preparedness supplies. S7 and S8 stated staff receive training regarding mass casualty incidents, fire events, power outages, poor air quality events, and other emergency situations.

On 02/12/2026, 03/05/2026, 04/03/2026, and 04/29/2026, LPA toured the facility and observed emergency food supplies, emergency drinking water, delayed egress systems, audible alarms, emergency preparedness equipment, and posted emergency information. LPA observed emergency food and water supplies maintained at the facility and observed no deficiencies related to emergency supplies, emergency equipment, or posted emergency information during the facility visits.

page 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 8