435202874-7-29-2026-26-AS-CKAI-DYE3GS-20260929181445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 05/26/2026
Date Signed: 07/29/2026 02:23:22 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
09/09/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250909093332

FACILITY NAME:	IVY PARK AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	PADILLA SANCHEZ, KENIA		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 38	DATE:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Executive Director (ED) Karen Nickolai		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure that resident's room is supplied with toilet paper
Staff did not ensure window coverings in hallways are changed.
Faclity is not meeting the resident's incontinence care needs

INVESTIGATION FINDINGS:

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*This is an amended report to remove a substantiated finding to a separate LIC9099. Please reference LIC9099 dated 7/29/2026 for substantiated finding.*

Licensing Program Analyst (LPA) Marcella Tarin conducted a complaint visit to deliver case findings. LPA met with Executive Director (ED) Karen Nickolai and stated the purpose of the visit.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250909093332

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 TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 05/26/2026

NARRATIVE

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*This is an amended report to remove a substantiated finding to a separate LIC9099. Please reference LIC9099 dated 7/29/2026 for substantiated finding.

Staff did not ensure window coverings in hallways are changed.
On 9/9/2025 the Department interviewed Reporting Party (RP). RP states on 9/4/2025, he/she observed the second floor hallway curtains to be soiled.

On 5/26/2026, the Department toured the second floor hallways and observed the curtains to be clean, and in good repair.

Staff did not meet resident's incontinence care needs
On 9/9/2025 the Department interviewed Reporting Party (RP). RP states on 9/3/2025 he/she observed a resident, referred to as R1, room to have soiled blinds, walls, bedding, doors and door handles. RP also stated he/she observed R1’s mattress to not have a mattress cover. RP stated he/she observed R1’s mattress to be soiled and unsanitary. RP stated this incident was reported to the Executive Director (ED) Karen Nickolai on 9/3/2025. RP stated on 9/4/2025 he/she did a walk through R1’s room with ED and observed R1’s toilet to be clean but other areas were ‘untouched.’

On 9/10/2025 the Department conducted the initial complaint investigation visit and obtained pertinent documentation.

On 05/26/2026, the Department interviewed ED, 4 Staff (S1 to S4), and 4 Residents (R1 to R4). 3 Out of 4 staff stated he/she assists residents with his/her care needs. S2 states he/she checks on resident at least every 2 hours, it all depends on the resident. S4 states he/she checks on residents 4 to 5 times per shift. S4 states he/she does not provide direct care to residents.

On 05/26/2026, the Department interviewed 4 Residents. 3 Out of 4 residents stated staff help him/her with their care needs. R2 did not respond to questions due to neurocognitive disorder.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250909093332

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 TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 05/26/2026

NARRATIVE

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*This is an amended report to remove a substantiated finding to a separate LIC9099. Please reference LIC9099 dated 7/29/2026 for substantiated finding.*

On 10/16/2025, during an unrelated visit, the Department toured R1’s room. R1’s room was observed to be clean, safe and sanitary. R1’s bathroom was observed with toilet paper.

On 05/26/2026, the Department toured 11 random resident rooms (107, 104, 109, 111, 119, 238, 236, 232, 211, 229, 201). 11 resident rooms were observed to be clean, safe, sanitary and in good repair.

Review of R1’s Physician’s Report dated 1/10/2025, R1’s Capacity for Self-Care states “No additional physician comments.” R1’s Activities for Daily Living Questionnaire for MD Review, not dated, notes “Bladder impairment, yes, episodes of incontinence.”

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director (ED) Karen Nickolai and a copy of this report was provided.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250909093332

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 TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 05/26/2026

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	This is an amended report to remove a substantiated finding to a separate LIC9099. Please reference LIC9099 dated 7/29/2026 for substantiated finding. Page 4 of 4 END OF REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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