435202847-3-16-2026-26-AS-RMAO-DTFS9W-20260424134124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202847
Report Date: 03/11/2026
Date Signed: 03/16/2026 08:14:08 AM

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 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: 112	DATE:	03/11/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Valerie Baldugo Associated Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not provide written report to responsible party of resident's medical condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation visit to deliver the findings of the above allegation. LPA met with Associate Executive Director (AED) Valerie Baldugo and stated the purpose of the visit. Executive Director (ED) Karina Nevarez was not present due to prior commitment.

On 09/02/2025, the Department received a complaint with the above allegation. On 09/03/2025, the Department conducted an initial investigation and requested documents. On 01/09/2026, 01/27/2026 and 02/05/2026, the Department continued with the investigation.

On 09/02/2025, LPA Steve Chang conducted an initial interview with witness 1 (W1). W1 stated that resident 1 (R1) was observed with a bruise and a skin tear on 07/28/2025 by witness 2 (W2). W1 stated that he/she did not observe the bruise himself/herself. W1 stated according to W2 the bruises were healing when W2 observed the bruise on 07/28/2025. ~~~~~ page 1 of 3 see LIC 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

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 3

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: 03/11/2026

NARRATIVE

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On 01/09/2026, LPA Partoza interviewed 2 staff. Staff 2 (S2) stated that R1 was observed with tiny bruises 6 months ago and was reported to R1s PCP. Staff 3 (S3) stated that R1 bruises easily and does not know how R1 gets the bruises.

On 02/05/2026, LPA Partoza interviewed W2. W2 stated that the facility did not notify R1s responsible party (RP) of the injury that R1 sustained a wound when R1 hit his/her foot on the wheelchair, however, W2 stated that “staff at the facility are typically good at reporting this type of incident to R1s RP.” W2 stated that the facility notified RP via phone on 08/28/2025, that R1s foot had a fluid filled blister on the left heel.

Based on R1s general chart notes from 07/12/2025 to 08/27/2025 there was no incident reported describing a wheelchair related injury, however, documentation from 08/25/2025 to 08/27/2025 noted lethargy and poor appetite. On 08/28/2025, general chart notes documented discovery of a blister, photo taken, and notification to the responsible party (RP), primary care physician (PCP) and former memory care director (MCD). Additional information that RP and PCP were notified later the same day. The facility reported the incident to Community Care Licensing Division (CCLD) on 09/02/2025.

Based on the R1s medical assessment dated 08/29/2025 R1s injury described a “serious foot injury requiring medical intervention.” Based on the policy review, the facility has a reporting policy consistent with California Code of Regulations (CCR) Title 22 section §87211, which requires facilities to notify the Department, the resident’s responsible party, and other appropriate agencies of incidents that pose a risk to resident health, safety, or personal rights.

During the investigation, documentation disclosed that the facility notified the responsible party (RP), primary care provider (PCP), and memory care director (MCD) on 08/28/2025 when R1’s left heel blister was discovered and later submitted the incident report to the Department on 09/02/2025, consistent with the reporting timelines and procedures outlined in CCR §87211.

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see LIC 9099C

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 03/11/2026

NARRATIVE

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Based on interviews and record review, the facility demonstrated compliance with its reporting obligations as required under §87211, R1s general chart notes did not contain written report regarding earlier wheelchair related injury.

Based on interviews and record reviews that pertains to the left-heel blister observed on 08/28/2025, although the allegation that the facility did not provide written reports to responsible party of resident’s medical condition 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.

No deficiencies were cited during today’s visit based on CCR Title 22. An exit interview was conducted with AED Valerie Baldugo and copy of the report was provided.

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC9099 (FAS) - (06/04)

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