435202847-12-12-2025-26-AS-RMAO-DPUKTM-20251230071122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 12/12/2025
Date Signed: 12/12/2025 03:51:48 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
08/13/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250813110545

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: 111	DATE:	12/12/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Senior Executive Director, Karina Nevarez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not maintain facility elevators in good repair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Senior Executive Director, Karina Nevarez and stated the purpose of today’s visit.

On 8/13/2025, the Department received a complaint with the above allegation. On 8/21/2025, the Department conducted an initial investigation at the facility. On 8/13/2025, two residents were stuck in the elevator due to elevators not being in good repair.

On 8/21/2025, LPA Rai interviewed 3 staff (S1-S3). 3 Out of 3 staff stated the facility elevators did have issues, but the facility management team did respond in a timely manner to ensure the elevators were evaluated by a professional technician.

Continuation on LIC 9099-C, Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

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 2

Control Number 26-AS-20250813110545

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: 12/12/2025

NARRATIVE

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S1 stated on 8/13/2025, when the incident occurred, the staff ensured the residents were safe and then called the elevator company. S1 stated the technician assessed the problem and it was a new issue with the elevator, so they were able to fix and the residents were able to use the elevator within 24 hours. Three out of three staff stated it was the first incident where this elevator had issues and did not work, but the issue was resolved within 24 hours.

On 8/21/2025, LPA Rai interviewed 10 residents (R1-R10). 2 Out of 10 residents stated they used the elevators a few minutes prior to the incident on 8/13/2025 and they did not see an issue to be reported to staff. 6 Out of 10 residents stated they were not aware of the incident on 8/13/2025 and the incident did not impact their day-to-day activities, which include meals, medication and activities. 10 Out of 10 residents stated they have no issues with facility not maintaining the facility elevators. R6 stated there is always one working elevator for residents to use. R10 stated the facility staff will notify the residents where the elevators are out of service for repairs or routine maintenance.

LPA Rai reviewed documents related to the elevator’s maintenance and service. Based on review of document of the facility elevators from 7/1/2025 – 8/19/2025, there were 7 incidents recorded of the elevator technician coming to the facility and inspected and repairing the elevators.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Senior Executive Director, Karina Nevarez and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2