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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 08/12/2026
Date Signed: 08/21/2026 11:16:37 AM

Substantiated


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
01/26/2026 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20260126122429
FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 47DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Karen NickolaiTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Due to lack of supervision, the resident fell sustaining an injury.
INVESTIGATION FINDINGS:
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*This is an amended report*
Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit.

On 1/26/2026 the Department received a complaint with the above allegation. It has been alleged that due to lack of supervision, a resident, referred to as R1, fell three times on 10/17/2025, 10/21/2025, and 10/26/2025. During R1's fall on 10/26/2025, R1 sustained a fractured vertebra (neck) during a fall while in care.

On 1/27/2026 the Department conducted the initial complaint investigation visit and met with ED Karen Nickolai. The Department obtained pertinent documentation.

Page 1 of 3

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026
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-20260126122429
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: 08/12/2026
NARRATIVE
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*This is an amended report*

Review of R1’s documentation dated 2/10/2025 and 2/14/2025, R1 has a history of falling. R1’s Assessment Form dated 2/14/2025, R1 is a fall risk, and requires queuing for transfers, requires status check every shift (Fall risk). R1’s Individual Service Plan dated 9/25/2025, R1 is noted as high fall risk and is under fall management to be provided by care provider.



R1’s charting notes that R1 fell while in care on the following dates: 10/17/2025, R1 fell hitting his/her head, with a laceration on temple, 10/26/2025 R1 fell while attempting to get out of bed, hitting her/her head and required medical attention. R1’s charting notes also note that R1 fell in care on 6/3/2025 hitting the left side of his/her body on the floor, and on 9/24/2025 R1 had another fall, resulting in a laceration on the left elbow.
Review of additional records for R1, note that R1 fell on 10/21/2025, hitting his/her head, which was not noted on R1’s charting notes.

Review of medical documents dated 10/26/2025, R1 sustained a fractured vertebra (neck), due to a fall at the facility.

On 7/8/2026, 7/27/2026, and 8/3/2026 the Department interviewed 5 Staff (S1 to S5). 5 Out of 5 did not know if facility management had conducted a fall assessment when R1 fell on 10/17/2025, 10/21/2025 and 10/26/2025.

Based on interviews with staff, S4 stated that R1 was a known fall risk because R1’s health was declining. S4 states that in October 2025, the facility did not have a health services director and had regional management staff supporting the facility. S4 states to have voiced concerns about R1’s falling to the regional corporate staff. S4 believed the regional corporate staff were aware of R1’s condition, however, S4 was not able to confirm if R1 had a new care plan and does not believe there were any fall preventions or new assessments for R1.

Based on interview with staff S5, it was stated that R1 was a known fall risk. S5 states a fall assessment should be conducted after every fall, and the fall assessments are completed by upper management.
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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 26-AS-20260126122429
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: 08/12/2026
NARRATIVE
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*This is an amended report *

S5 states to have verbalized concerns about R1’s falls to the regional management but does not remember receiving any new directives for R1’s fall management. S5 states that during his/her month of employment, the senior management was short staffed as there was no permanent senior wellness nurse to report to consistently. Although corporate sent different regional nurses for coverage from September 2025 – October 2025, S5 states to have felt understaffed because he/she was responsible for overseeing memory care and assisted living residents and staff, when S5 was “barely” trained.

Based on review of R1’s records, there are no documented reassessments or additional fall prevention measures after R1 fell on 10/17/2025 and 10/21/2025.



Based on observations, interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC 9099D. A separate case management visit was conducted on 08/12/2026 due to a violation found during the investigation.

An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review.

An exit interview was conducted with Executive Director (ED) Karen Nickolai. A signed copy of this report and appeal rights were provided.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20260126122429
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/13/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Licensee will submit a plan of action stating how they will ensure the personal rights of residents are upheld, including the right to care, supervision and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency. to meet their needs. POC due by POC due date 8/13/2026.
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This was not met as evidenced by:
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*This is an amended deficiency* Based on interviews and record review, the licensee did not comply with the section cited above wherein the management staff was not competent to provide the care and supervision to meet resident (R1)’s needs after being informed of concerns by staff of resident (R1) being a fall risk resulting in R1 sustaining a fractured vertebra which poses an immediate health, safety, and personal rights risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 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
01/26/2026 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20260126122429

FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE:CAZIP CODE:
95117
CAPACITY:82CENSUS: 47DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Karen NickolaiTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Licensee does not ensure staff are properly trained
Staff do not follow residents care plan
Staff did not notify authorized representative of incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit.

On1/26/2026 the Department received a complaint with the above allegations.

On1/27/2026 and 2/19/2026 the Department interviewed 3 staff (S1 to S3). 3 Out of 3 Staff stated he/she was provided training by the facility.

On 7/8/2026 and 8/12/2026 the Department interviewed 5 Residents (R2 to R6). 5 out of 5 residents stated he/she does not have any concerns with the care he/she is receiving.

Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20260126122429
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: 08/12/2026
NARRATIVE
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On 2/19/2026 and 8/12/2026 the Department reviewed 3 staff records. 3 Out of 3 staff have training documented for 2025 and 2026 to include but not limited to transfers, dementia behaviors. Staff in-service training records from January 2026 to July 2026 were reviewed, topics included but not limited to elopement drills, fall management protocols.

Staff do not follow residents’ care plans
RP states Resident R1 fell due to staff not knowing how to care for R1 as a fall risk.

On 1/27/2026 and 2/19/2026 the Department interviewed 3 staff (S1 to S3). 3 Out of 3 Staff stated he/she has training on resident fall prevention/protocols. 3 Out of 3 staff stated he/she can obtain information about resident’s care plans in the resident’s binders, as well as reviewing resident progress notes.

On 7/8/2026 and 8/12/2026 the Department interviewed 5 Residents (R2 to R6). 5 out of 5 residents stated he/she does not have any concerns with the care he/she is receiving.

On 2/19/2026 and 8/12/2026 the Department reviewed 3 staff records. 3 Out of 3 staff have training documented to include but not limited to transfers, dementia behaviors for 2025 and 2026. Staff in-service training records from January 2026 to July 2026 were reviewed, topics included but not limited to elopement drills, fall management protocols.

Although the allegations may have happened or is 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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END OF REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 6 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
01/26/2026 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20260126122429

FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE:CAZIP CODE:
95117
CAPACITY:82CENSUS: 47DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Karen NickolaiTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff installed cameras in residents’ room without consent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit.

On 1/26/2026 the Department received a complaint with the above allegation.

On 1/26/2026 the Department interviewed Reporting Party (RP). RP states he/she does not have any issues with the facility’s use of video surveillance.

The facility has on file with Community Care Licensing Division (CCLD) an approved waiver for the use of video surveillances. Written informed consent forms have been provided to current and any prospective residents upon admission to the facility.
Page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20260126122429
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: 08/12/2026
NARRATIVE
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This agency has investigated the complaint alleging staff installed cameras in residents’ room without consent We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

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

Page 2 of 2
END OF REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8