435202847-5-1-2026-26-AS-MPAA-DTNPFS-20260501111711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 04/29/2026
Date Signed: 05/01/2026 11:20:26 AM

Document Has Been Signed on 05/01/2026 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	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: 115	DATE:	04/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:37 AM
MET WITH:	Karina Nevarez & Valerie Baldugo		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and met with Associate Executive Director/Administrator (AED) Val Baldugo and stated the purpose of the visit. Executive Director/Administrator (ED/ADM) arrived at a later time. The facility serves adults ages 60 and over, 140 non-ambulatory, 21 may be bedridden and hospice waiver for 15. LPA toured the interior of the facility, including entryway, lobby, resident room hallway, common area, dining area, kitchen, fire escape staircase, laundry room, emergency food supply area, medication room, activity area, 6 Assisted Living (AL) resident rooms, and 4 (2 shared & 2 private) Memory Care (MC) resident room and bathrooms. LPA observed that designated emergency exits are clear from obstruction and tripping hazard, however, LPA observed yellow caution tape on the entry ways due to ongoing exterior facility maintenance. Facility is a three story building, reception lobby where most residents sits, socialize, meet friends, and wait for their transportation. The exit doors are equipped with wander guard that alerts staff for resident who have exit seeking behaviors. Facility has activities scheduled posted for the whole month of April and posted conspicuously in the facility hallways, dining area, elevator, hallways, residents in the AL area received monthly activity calendar of events. LPA observed residents participating during one of the activity time in the MC and the AL area. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

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

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/29/2026

NARRATIVE

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MC area of the facility is equipped with delayed egress and working audible alarms. LPA observed rodent traps under the counter cabinets of the MC Unit. LPA did not observe any food stored that may be attracting the rodents. AED stated that the counter top with the food warmer is not in use.

The facility kitchen is equipped with walk-in commercial grade refrigerator and freezer. Doors going to the kitchen have locks when not in used and are not accessible to residents. LPA observed emergency drinking water supply, 7 days for non-perishable food and emergency food supply (easy to prepare meal). The facility has snack bars in the activity areas. The kitchen is kept sanitary and organized. LPA inspected the freezer area, and observed that the facility has sufficient perishable food supply for 2 days or more. The walk-in refrigerator and freezer is cleaned 3 times or more a week.

The dishwashing area and hot water temperature delivers over 125 degree F and warning sign is posted that the tap delivers hot water over 125 degree F. Kitchen staff were observed sweeping, wiping surfaces and organizing the kitchen after morning meals were served. LPA observed the dining area floors are kept sanitary. There were residents still present at the dining area at the time of inspection. The refrigerator temperature is at 31 degree F and the freezer temperature is at 0 degree F.

LPA inspected assisted living (AL) residents room and memory care (MC) resident room. LPA observed that resident rooms have sufficient storage space for their personal belongings. Based on 5 out of 5 staff interviews, AL and MC are cleaned once a week and laundry are done once a week. Unless otherwise necessary, such as emergencies and behavioral challenge such as but not limited to smearing food and throwing food. The caregivers, and medication technicians will step in to keep the residents room in a safe and sanitary condition to prevent any infestation of ants and other insects, especially when housekeeping is not available. Based on review of the admission agreement extra cleaning for the week will incur a fee. The resident rooms were observed to be sanitary and organized.

The AL and MC hot water temperature were measured with a digital thermometer, the temperature ranges between 115 degree F to 118.9 degree F.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/29/2026

NARRATIVE

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LPA conducted 5 staff interview and interviewed 5 residents in the AL area and 1 in the MC area. LPA reviewed 10 staff record for current training, background clearance, personnel file and current certifications. LPA reviewed 10 resident record such as individual care plans, physician's report (LIC 602), personal rights, admission agreement, consent forms to name a few. Medication record will need to be reviewed at a future date due to time constraint.

LPA conducted a facility file review and verified that the facility conducts the fire and disaster drill training each month and given by Fire Safety Service, Inc. The last drill training was given on 04/13/2026. The facility maintains Ecolab to monitor and exterminate possible pest in the MC area. Based on record review Ecolab comes to the facility each month and or as needed to monitor the traps set at the MC kitchen area.

The facility has fire extinguishers that are strategically placed in each floor and were last inspected on 05/15/2025 and 05/19/2025. The facility is equipped with fire alarm and carbon monoxide alarm system. The facility has a fire alarm panel that alerts the fire department in case of a fire. The facility is equipped with manual wet standpipe to be used in case of fire and water sprinklers. The facility ha emergency evacuation chairs for each fire escape staircase.

Due to time constraint the required 1 year annual inspection will be continued at a later date.

No deficiency was cited during today's annual required visit. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Karina Nevarez and Associate Executive Director (AED) Valerie Baldugo and a copy of the report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC809 (FAS) - (06/04)

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