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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 05/28/2026
Date Signed: 05/28/2026 03:32:18 PM

Substantiated


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
03/25/2026 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20260325084408
FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 38DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karen NickolaiTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not provide adequate supervision resulting in resident eloping from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Karen Nickolai, Administrator. On 03/27/2026, LPA Marrufo conducted an initial complaint investigation visit.

On 03/27/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report states R1 has a primary diagnosis of dementia and is not able to leave the facility unsupervised.

See LIC9099-C page for more information. Page 1 of 4.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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-20260325084408
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: 05/28/2026
NARRATIVE
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On 03/27/2026, LPA Marrufo obtained a copy of R1’s Individualized Service Plan (ISP), dated 08/21/2025. The Wandering section of R1’s ISP states, “Resident wanders into apartments agitating other residents. Receives observation and assistance when wandering.” The Exit Seeking section states, “Resident verbalizes desire to leave, may seek out exit doors throughout the day; will peer through door windows or loiter near exit but does not attempt to leave secured area, requiring no additional staff time. Receives observation and assistance when seeking exits. Closely observe and guide when seeking exits. Cue or redirect for safety. Resident need[s] to be on frequent checks. Lacks safety judgements.”

On 03/25/2026, the facility submitted an Unusual Incident/Injury Report (IR). The IR was submitted on 03/25/2026. The IR states that on 03/24/2026, staff last observed R1 near the Activities Director on the first floor around 4:00 PM and was brought upstairs to memory care by the Activities Director. Around 5:00 PM, staff noted R1 was missing from the Memory Care Unit. Staff called 911. Around 6:30 PM, police officers located R1 on Doyle Road.

On 03/27/2026, LPA Marrufo interviewed S1-S9. During interviews, S4, S7, S8, and S9 stated to have been involved with R1’s elopement from the facility on 03/24/2026.

During interview, S4 stated R1 took the stairway down from the Memory Care unit on the second floor to the first floor and exited the facility building through an emergency exit. S4 stated none of the staff heard the emergency exit door alarm. S4 stated he/she and other staff searched each resident room of the facility looking for R1 and then began to search for R1 in the surrounding community outside the facility building. S4 stated police found R1.

During interview, S7 stated that he/she was driving away from the facility when staff called him/her and notified him/her that R1 had eloped from the facility. S7 stated R1 had eloped from the facility about five minutes prior to S7 receiving the call from staff. S7 stated he/she began driving back to the facility while instructing staff to utilize the elopement bin, which includes the elopement checklist.


Page 2 of 4.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20260325084408
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: 05/28/2026
NARRATIVE
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During interview, S8 stated he/she is the Activities Director. S8 stated he/she had taken R1 out of the facility for an outing and returned with R1 at around 3:30 PM. S8 stated he/she walked R1 back up to the Memory Care unit of the facility on the second floor. S8 stated he/she later observed R1 with another resident in the art studio on the first floor. S8 stated he/she walked R1 and the other resident back up to the activity room in the second floor. S8 stated that when he/she arrived to the second floor activity room, he/she made eye contact with the staff inside the activity room and told the staff that R1 and the other resident were now with him/her. S8 stated staff began searching for R1 after S8 had left the facility around 5:00 PM.

During interview, S9 stated that prior to R1’s elopement on 03/24/2026, R1 has had previous elopement attempts. S9 stated that R1 has made previous attempts to exit through the exit door that is at the end of the stairway at the end of the hall. S9 stated staff usually redirect R1 when he/she is going down the stairs or is at the door. S9 stated there have been times when R1 reaches the door and opens it, but the exit alarm startles R1 and he/she does not leave the facility. S9 stated that on 03/24/2026, he/she was in another resident’s room while that resident’s family member was visiting. S9 stated the resident’s family member said he/she heard an alarm, but S9 did not hear it. S9 stated that R1 was under his/her charge so he/she went to look for R1 in every apartment in the upstairs and downstairs levels in the facility. S9 stated after searching for R1 for around 20-30 minutes, he/she notified the medication technician on duty. S9 stated the medication technician then notified the rest of the staff on duty that R1 had gone missing. S9 stated he/she believes ADM was notified around the same time S9 had notified the medication technician. S9 stated he/she did not inform ADM because he/she assumed someone else had already done so.

During visit on 03/27/2026, LPA Marrufo interviewed ADM. During interview, ADM stated R1 eloped through the side exit and set off the door alarm. ADM stated staff did not notify ADM of R1’s elopement until 30 minutes after staff realized R1 had eloped. ADM stated she immediately called 911 and used her personal vehicle to look for R1 in the neighborhood surrounding the facility. ADM stated police officers found R1 and brought R1 back to the facility.

Page 3 of 4.

END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20260325084408
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2026
Section Cited
CCR
87705(e)(3)
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Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to
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Licensee agrees to submit a Plan of Correction by 05/29/2026 stating how the licensee will conduct in-service training with staff on ensuring that staff redirect a resident at risk for elopement who may be attempting to leave the facility.
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leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Licensee did not ensure that facility staff redirected R1 as he/she left the facility, posing an immediate safety risk to residents in care.
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Once training is complete, the licensee agrees to submit training records that include name of staff trained, training dates, training topics, and names and qualifications of trainers.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/25/2026 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20260325084408

FACILITY NAME:IVY PARK AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 38DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karen NicholaiTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident was left on the floor for an extended period of time due to lack of supervision
Staff do not prevent residents from harming themselves
INVESTIGATION FINDINGS:
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When the department received the complaint, it was alleged that residents were falling onto the floor for over two hours without receiving assistance from staff.

On 03/27/2026, LPA Marrufo obtained a copy of the SafelyYou resident report. SafelyYou is a fall detection and alert technology. The SafelyYou resident report states that SafelyYou is installed in 36 resident rooms and not installed in 15 resident rooms. The Resident Statistic section of the SafelyYou resident report states there were 15 residents who had experienced at least one fall within the last 30 days, as of 03/27/2026.

On 03/27/2026, LPA Marrufo toured the facility. During facility tour, LPA observed 11 residents. LPA Marrufo did not observe any signs of bruising on the visible parts of the residents’ arms and heads.

See LIC9099-C page for more information. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20260325084408
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: 05/28/2026
NARRATIVE
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During visit on 03/27/2026, LPA Marrufo interviewed residents R2-R5. During interviews, R2-R5 stated they have not observed a resident being left on the floor for an extended period.

During visit on 03/27/2026, LPA Marrufo interviewed staff S1-S9. During interview, S1-S9 stated to have not observed a resident left on the floor for an extended period of time. S2 and S7 stated staff are alerted and are able to see a video of resident falls. During visit on 03/27/2026, LPA Marrufo interviewed Administrator (ADM) Karen Nickolai. During interview, ADM stated that she has not observed residents being left on the floor for an extended period of time.

On 05/28/2026, LPA Marrufo conducted telephone interviews with FM1, family member of R6, FM2, family member of R7 and FM3, family member of R8. During interviews, FM1-3 stated to have not observed residents being left on the floor for an extended period of time.

Allegation: Staff do not prevent residents from harming themselves
When the department received the complaint, it was alleged that residents commit suicide on premises.

During visit on 03/27/2026, R2-R5 stated they have not observed any residents attempt suicide at the facility. During visit on 03/27/2026, S1-S9 stated no residents have attempted suicide at the facility. During visit on 03/27/2026, ADM stated no residents have attempted suicide at the facility. On 05/28/2026, LPA Marrufo conducted telephone interviews with FM1, family member of R6, FM2, family member of R7, and FM3, family member of R8. During interviews, FM1-3 stated to have not observed residents attempt suicide at the facility or staff not preventing residents from harming themselves.

On 05/28/2026, LPA Marrufo obtained copies of Internal Incident Reports and Unusual Incident/Injury Reports from February and March 2026 and did not observe any reports of residents posing a danger to themselves. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the agency has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This report was reviewed with Karen Nickolai and a copy of this report was provided.
Page 2 of 2. END REPORT.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20260325084408
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: 05/28/2026
NARRATIVE
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Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See LIC9099-D for a deficiency cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Karen Nickolai and a copy of this report and appeal rights were provided.



Page 4 of 4.



END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7