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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 02/24/2026
Date Signed: 02/24/2026 01:57:35 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
09/02/2025 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20250902144233
FACILITY NAME:IVY PARK AT SAN JOSEFACILITY NUMBER:
435202847
ADMINISTRATOR:BALDUGO, VALERIEFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE ROADTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: 114DATE:
02/24/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Karina NevarezTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Resident sustained pressure injury due to neglect and lack of supervision
Facility did not seek timely medical attention for resident's pressure injury
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 (ED) Karina Nevarez and stated the purpose of the visit.

On 09/02/2025, the Department received a complaint with the above allegations. On 09/03/2025, the Department conducted an initial 10-day investigation visit. On 12/03/2025, the Department received the medical records of Resident 1 (R1). On 01/09/2026, 01/27/2026 and 02/05/2026, the department continued the investigation. LPA Partoza conducted interviews and reviewed received documents such medical assessment, appraisal needs and services plan and progress notes.

see LIC 9099C
page 1 of 4
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
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 5
Control Number 26-AS-20250902144233
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: 02/24/2026
NARRATIVE
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On 09/02/25, LPA Chang interviewed Witness 1 (W1). W1 reported that on 08/29/25, Resident 1 (R1) and R1’s responsible party (RP) met with R1’s wound care physician for treatment of a Stage 1 pressure injury. W1 stated that based on his/her observations, W1 believes R1 experienced neglect or lack of supervision by the facility. W1 stated that the facility applied a Band-Aid to R1’s wound and did not provide timely or appropriate wound care. W1 further indicated that facility staff were responsible for R1 sustaining the pressure injury on his/her heel. W1 further states that RP told W1 that around 07/28/25, RP saw bruises on R1s arms and a skin tear, there was no report or documentation of the injury. RP continued to state to W1 that RP inquired about the injury with the former Memory Care Director (MCD) who stated that he/she will investigate the bruises but did not give an update to RP.

On 01/09/26, LPA Partoza continued with the investigation and interviewed 3 staff (S1 to S3). S1 stated that he/she is not aware of R1s pressure injury on the foot, however, remembers R1 having a pressure injury prior to moving to MC, and it was on the back, it is no longer there. S2 stated R1 gets upset with care and is aggressive. S2 stated R1 can bruise easily because of his/her heart medication. S2 stated R1 came from a different facility, and he/she had a pressure injury on the back at that time. S2 stated that he/she remembers that R1 developed a pressure injury on his/her heel, but not sure how. S2 stated that caregivers elevate R1s legs every two hours. S2 stated when the medication technicians (MT) on duty was notified by the care staff of R1s wound, MT called the doctor and notified RP right away S2 stated R1 has a lot of skin problems on his/her legs, and memory care staff take care of R1. S2 stated "currently, R1s pressure injury is healing well." S3 stated that "R1 is aggressive especially during his/her ADLs, R1 likes to punch, kick and flay his/her arms to staff. It will take three care staff to change R1." S3 stated he/she "I put cream on R1s rashes. R1 skin is very sensitive. When he/she move R1 foot to elevate, R1 screams because it's painful. R1 will say ouch, ouch whenever they move or reposition his/her foot."

On 01/27/2026, LPA interviewed 1 staff (S4). S4 stated he/she has not seen a staff neglect a resident that may have caused a pressure injury. Staff give residents proper care and turn residents who are bed bound every two hours to avoid rashes. S4 stated R1 is aggressive and says something inappropriate, pinches and taps staff. S4 stated it does not hurt but for the most part R1 is nice. S4 stated that as caregivers they do body checks and if they see something that was not there before, they report to the MT on duty. For any life threatening situation they call 911. ---- page 2 of 4
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20250902144233
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: 02/24/2026
NARRATIVE
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On 02/05/26 LPA Partoza interviewed RP. RP stated that he/she visits R1 at least 3 to 4 times a week. RP stated that R1 is declining rapidly, does not want to eat or drink. RP stated that he/she was at the facility a lot and does not know how he/she missed the wound on R1s heel. RP stated what upset him/her was that he/she saw there was puss and blood coming out of R1s heel. RP stated he/she felt bad, R1 had the slip on “crocs” and saw there was liquid on R1s shoes for 2 days. RP stated, “he/she thinks it’s been going on for more than a week; it was not addressed that’s why it got bad so fast.” RP stated he/she cannot speculate how R1 sustained the pressure injury because he/she is not at the facility 24/7. RP stated "the reason they (staff) gave me was that R1 hit his/her heel on the wheelchair." RP stated that he/she was notified by staff regarding R1s pressure injury on 08/28/2025. RP stated the week before, R1 did not have socks on and after a week went by, it went from a small wound to a pressure injury, and when RP saw the wound next (08/28/25) it was already a pressure injury. RP stated, “I was just kind of shock that former MCD were cleaning R1s wound in the dining room.” RP stated that three (3) people give care to R1.

On 02/05/2026, LPA interviewed 2 staff (S5 & S6) S5 stated that R1 is okay. R1 has dementia and sometimes R1 is nice sometimes not. S5 stated he/she saw R1 with the wound on his/her left heel. S5 stated he/she does not know how R1 got that injury. S5 stated "I report the problem to the med tech." S5 stated he/she does body checks on R1 before showering. S5 stated. It was probably 3 months or more ago that I observed the wound on R1s heel. I tried to give R1 a shower when I saw the wound for the first time. I was scared, I saw the problem, I saw blood on the heel and liquid coming out. I gave him/her a shower, and I reported to the MT on duty. Then I went back to do my other assignments.”

S6 stated, “yes, I did see R1 with a wound on his/her left heel. I first saw it was around October or September and I saw fluid leaking from his/her heel. It was reported by S5. I notified R1s responsible party (RP), his/her PCP and our former MCD." S6 stated, he/she remembers calling 911 and R1 was taken by 911. S6 stated he/she does not know how R1 sustained the wound. S6 stated that former MCD came and looked at R1s wound and does not remember what MCD did next. S6 stated “At that time, R1 was not under hospice care; hospice began after R1 returned from the hospital.” S6 described R1 as able to move the upper body but not the lower body, rarely moving his/her legs, and usually sleeping on his/her back. S6 believed the injury was due to immobility.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20250902144233
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: 02/24/2026
NARRATIVE
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Based on document and record review, R1 was admitted to the facility on 09/20/2023. R1’s medical assessment dated 03/13/2025, stated that R1 exhibits aggressive behavior when getting out of bed. R1 is non-ambulatory due to both physical and cognitive conditions. R1’s individual care plan, dated 07/17/2025, specifies that during showers, R1’s wound should be cleaned with warm water, avoiding scrubbing, then gently patted dry. Staff are instructed to notify the medication technician (MT) or nurse to rewrap or redress R1’s foot. When transferring R1, staff must exercise caution with R1’s feet and ensure both legs are elevated every two hours. If R1 expresses discomfort, staff must notify the nurse or MT on duty immediately. R1 requires assistance from two staff members for transfers. Medical records indicate R1 is diagnosed with depression, dementia with behavioral disturbance, hypertension, and chronic osteoarthritis. On 08/24/25, R1 pulled a staff member’s hair during assistance with activities of daily living (ADLs). On 08/27/25, R1 exhibited a lack of appetite and was continuously monitored. On 08/28/25, at approximately 0800 hours, Care Staff (S5) informed S6 that R1 was observed with pink and white fluid on the left heel prior to showering. S6 photographed the heel, and notified R1’s responsible party (RP), primary care physician (PCP), and the facility’s former Medical Care Director (MCD).

On 08/29/25, R1 was evaluated at Stanford Health Care, accompanied by RP, and diagnosed with cellulitis of the lower leg, an open wound on the left heel, a Stage 1 pressure injury on the right heel, tinea pedis (athlete's foot) on both feet, and dementia with behavioral disturbance. The report noted that R1 has no appetite for four days and demonstrated increased aggressive behaviors, including agitation while seated in a wheelchair. On 09/05/25, RP initiated hospice admission for R1.

Based on record review and interview, although the allegation 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 that resident sustained pressure injury due to neglect and lack of supervision and facility did not seek timely medical attention for resident's pressure injury are unsubstantiated.

No deficiencies were cited during today's visit. An exit interview was conducted with ED Karina Nevarez and a copy of the report was provided.
page 4 of 4 --- end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5