435202953-6-21-2026-26-AS-CCHG-DV9PPN-20260621112945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202953
Report Date: 06/19/2026
Date Signed: 06/21/2026 11:30:18 AM

Document Has Been Signed on 06/21/2026 11:30 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 LOS GATOS		FACILITY NUMBER:	435202953
ADMINISTRATOR/ DIRECTOR:	HOLTMAN, ERIKA		FACILITY TYPE:	740
ADDRESS:	400 BLOSSOM HILL ROAD		TELEPHONE:	(408) 560-9618
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY: 150		CENSUS: 40	DATE:	06/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Jonthan Ward		TIME VISIT/ INSPECTION COMPLETED:	04:41 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 Analysts (LPAs) Steve Chang conducted an unannounced annual inspection visit and met with maintenance director (MD) Jonthan Ward and Memory Care Director Blanca Evia Del Puerto. The facility is a 3 story building with 78 assisted living resident rooms and 36 memory care resident rooms. LPAs toured the facility with MD. LPAs toured the first floor including main entrance, reception area, lobby, dining room, kitchen, activity room, laundry room, Bristol area, library, TV room, mail room, restrooms, Med room, assisted living resident rooms, and two court yards. Med room was observed locked. Med cart and med refrigerator were observed locked. Laundry room was observed locked. LPA toured with MD 3 AL resident room on the first floor. Room temperature was observed at 73 degree F, Hot water was measured at 112 degree F in resident room. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested and they were working. The temperature of the freezer was measured at 0 degree F, and the temperature of the refrigerator was measured at 37 degree F. The floor of resident room bathroom were observed as resistant slipping floor. LPA checked 3 elevators, all were functional. LPA toured the second floor with MD. LPA checked 3 resident rooms and common restrooms. Continue on LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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 LOS GATOS	FACILITY NUMBER: 435202953
	VISIT DATE: 06/19/2026

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LPA toured the third floor with MD. LPA toured the memory care dining room, activity room, Salon room, memory care small kitchen, and sun deck. LPA tested the memory care delayed opening exit doors and they were functional. Med room, med cart and med refrigerator in the third floor were observed locked. LPA checked 3 memory care resident rooms. Housekeeper rooms were observed locked.

Fire extinguishers were serviced on 5/13/2025. MD stated the ire extinguishers appointment is scheduled on 6/27/2026 due to the management company change.

Evacuation Chairs were observed at the 3 stairs.

LPA reviewed 4 staff files.

LPA will continue on reviewing another 4 resident files.

A continue inspection visit will be conducted.

Exit interview was conducted with MD. The report was provided to MD for review and signature..

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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