435202874-5-11-2026-26-AS-RMAO-DU8PPB-20260519112912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 05/11/2026
Date Signed: 05/11/2026 02:28:21 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
04/01/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260401123849

FACILITY NAME:	IVY PARK AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	NICKOLAI, KAREN		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 37	DATE:	05/11/2026
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator Karen Nickolai		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff do not ensure resident's rooms are clean/sanitary
Staff did not ensure resident's hydration needs were met
Staff does not ensure resident's are personal hygiene needs are being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Karen Nickolai

On April 1, 2026, the Department received a complaint alleging Staff do not ensure resident's rooms are clean/sanitary.

On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she has found R1’s bedroom, as dirty and unsanitary. W1 stated he/she has found the bedsheets as soiled. W1 stated he/she has also noticed feces on the floor as well. W1 stated if staff are actively checking on R1’s bedrooms, then they would have noticed the soiled linens and the feces on the floor.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they have not had any issues with the housekeeping and/or the cleanliness of his/her bedroom.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated they have never seen a residents room’s cleaning neglected. 9 Out of 9 staff (S1-S9) stated have never seen or heard about any issues regarding the housekeeping of residents bedrooms and the facility as a whole.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Maintenance Director Chavez, referred to as MD. MD stated he inspects all the residents bedrooms weekly. MD stated there hasn’t been an instance where he observed or heard about a residents bedroom being neglected or not clean.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC and Health Services Director Kyleigh Whitely. RCC and HSD stated they have never seen a residents room’s cleaning neglected.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator (ADM) Karen Nickolai. ADM stated when she first started as administrator (September 2025), there was issues with the housekeeping. ADM stated this was addressed. ADM stated she fired all the housekeeping and had hired 3 new housekeeping staff. ADM stated the facility hasn’t had any issues since then, in terms of keeping residents bedrooms clean.

On April 9, 2026, Licensing Program Analyst Manuel Monter toured the facility inside and out with Administrator Karen Nickolai. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. LPA did not observe any resident bedrooms as unsanitary/ unclean/ disrepair.

On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 6 Out of 6 residents (R1,R5-R9) stated they have not had any issues with the housekeeping and/or the cleanliness of their bedroom. Page 2 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated they have not seen any instance were a resident’s bedroom was in an unsanitary state/neglected state.
On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated sometime in the beginning of March 2026, he/she did observe R1’s bedroom’s housekeeping needs as neglected. W2 stated he/she observed several dozens sheets of tissues on the floor. W2 stated after these 2 occasions, there hasn’t been any other issues regarding the housekeeping of R1’s room.

The Department reviewed the facility’s Housekeeping Log for the month of March & April 2026. Based on a review, all bedrooms in the memory care unit are listed and checked if the bedroom houskeeping cleaned said bedroom. The log also notes any issues discovered by housekeeping and if a certain task was not completed or if a resident refused service that day.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff did not ensure resident's hydration needs were met

On April 1, 2026, the Department received a complaint alleging Staff did not ensure resident's hydration needs were met

On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she believes the facility was not actively providing and offering his/her family member water.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they do not need assistance with eating or drinking. 3 Out of 3 residents (R2-R4) stated they are not aware of any issues of instances where residents were not assisted with meals and liquids. Page 3 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated the staff is aware they need to offer the residents water and actively prompt memory care residents to drink and eat. 9 Out of 9 staff (S1-S9) stated they haven’t seen any residents that were neglected assistance with feeding and eating.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC. RCC stated during meal times, the caregivers will help the residents who, are known by the facility, who need assistance as part of their plan of care. RCC stated the care givers will also watch over the other residents. RCC stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. RCC stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Health Services Director Kyleigh Whitely, referred as HSD. HSD stated during meal times, the caregivers will help the residents who need assistance as part of their plan of care. HSD stated the care givers will also watch over the other residents. HSD stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. HSD stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating.

On April 9, 2026, Licensing Program analyst Manuel Monter interviewed Administrator (ADM) Karen Nickolai. ADM stated all staff, even herself, are responsible for assistance in feeding and drinking water. ADM stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. ADM stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating.

On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 6 Out of 6 residents (R1,R5-R9) stated the facility provides/offers residents with waters, including during and after activities. 5 Out of 6 residents (R1,R5-R7, R9) stated they do not need assistance with eating or drinking during meals. Resident R8 stated he/she does need assistance during meals, which includes assistance with drinking liquids. R8 stated here hasn’t been a time when she was not assisted or neglected during meals. Page 4 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated during breakfast, lunch dinner, staff assist residents. 2 Out of 2 staff (S10-S11) stated staff makes sure residents drink their liquids to stay hydrated.

On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated R1 doesn’t need assistance with eating or drinking. W2 stated he/she isn’t at the facility long enough to see if they are offering and queuing R1 to drink water. W1 stated he/she hasn’t noticed.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff does not ensure resident's are personal hygiene needs are being met.

On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she believes that the facility is not checking residents diapers and changing them every 2 hours. W1 stated almost every time he/she visits R1, he/she has found his/her soiled and wet. W1 stated it is possible his/her R1 had just wet him/herself. W1 stated he/she doesn't have the details of the times and dates when he/she found his/her R1 wet.

W1 stated he/she has also observed that R1 has not had his/her cloths changed or his/her hair brushed on numerous occasions. W1 stated R1 would be wearing cloths in reverse such as shirts or pants. W1 stated he/she has found R1 not showered. W1 acknowledged that R1 will refuse showers as well.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they not need assistance with their grooming. 3 Out of 3 residents (R2-R4) stated they have not observed residents in a disheveled stated.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated there hasn’t been a time when they saw a resident that was neglected their showering needs. 9 Out of 9 staff (S1-S9) stated there hasn’t been a time when they saw a resident that was neglected residents grooming needs.

7 Out of 9 staff (S1-S5, S8-S9) stated there hasn’t been a time when he/she saw a resident who was neglected their changing needs or observed residents who’s changing needs were neglected for an extended period.

2 Out of 9 staff (S6-S7) stated they has observed instances where a resident was not changed, resulting in leaving a resident soiled for an extended period. S6 stated he/she has seen this happen once a month, due to previous shifts. S6 stated he/she can’t give an example of who in particular, since its sporadic.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC. RCC stated he/she has not observed any issues regarding the changing of residents. RCC stated there hasn’t been a time when he/she saw a resident who was neglected their changing needs or observed residents who’s changing needs were neglected for an extended period.

On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Health Services Director Kyleigh Whitely, referred as HSD. HSD stated there hasn’t been a time when he/she saw a resident that was neglected their showering needs. HSD stated there hasn’t been a time when he/she saw a resident that was neglected residents grooming needs. HSD stated she hasn’t seen any residents who’s grooming needs were neglected.

On April 9, 2026, Licensing Program Analyst Manuel Monter toured the facility inside and out with Administrator Karen Nickolai. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. LPA did not observe any resident in a soiled, disheveled, or unkempt state.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20260401123849

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: 05/11/2026

NARRATIVE

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On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 2 Out of 6 residents (R1,R5-R9) stated R1 R5 stated she doesn’t need assistance with grooming/bathing/ changing / using the restroom. 6 Out of 6 residents (R1, R5-R9) stated they haven’t’ seen any resident in a disheveled state or in a neglected state. 4 Out of 6 residents (R6-R9) stated they need assistance with showers. 3 Out of 6 residents (R6, R7, R9) stated there hasn’t been a time when she had missed a shower or was neglected bathing assistance. R8 stated there has been at least one time when he/she didn’t receive his/her shower. R8 stated his/her shower was scheduled for the morning and the staff offered to give it in the afternoon. R8 clarified he/she did receive his/her shower, but noted it was late.

On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated there hasn’t been a time when she saw a resident who’s grooming needs were neglected. 2 Out of 2 staff (S10-S11) stated there hasn’t been a time when a resident was neglected their showering needs.

S10 stated there have been instances where he/she has found residents left soiled from the previous shift. S10 stated he/she can’t say for sure when this occurred. S10 stated this occurred 2-3 times since he/she has been working at the facility. S10 stated it hasn’t occurred since he/she complained to management about it.

On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated there was two instances where he/she has found R1 soiled, fluids leaking from the place he/she was sitting. W2 stated he/she didn’t personally check or know if the soilage was fresh or had been there for some time. W2 stated this also occurred in the first weeks of March as well. W2 stated there hasn’t been any other issues with R1 being changed or groomed. W2 stated he/she hasn’t observed anything or noticed any issue.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

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