Inspection Reports for
Ivy Park at Milpitas

The complaint alleged that staff did not implement a proper facility emergency plan during a power outage on 12/26/2025. The investigation included interviews with the Executive Director, Maintenance Director, staff, and residents, and review of the emergency and utility outage plans. The complaint was found to be unfounded.

The investigation found that the facility had a proper emergency plan and staff followed it during the power outage on 12/26/2025. Residents were checked regularly, meals were delivered to rooms, and families were notified. The allegations were determined to be unfounded.

The Licensing Program Analyst toured the memory care unit, tested exit doors and gates requiring codes, observed the locked medication room with two med carts, and reviewed staff in-service training logs from December 2025 to February 2026. No citations were noted during this visit.

The visit was an unannounced complaint investigation to amend the complaint delivered on 12/30/25 (26-AS-20241017082303).

No deficiencies were cited at this time as per California Code of Regulations Title 22. The report was reviewed with the Executive Director and a copy was provided.

Two complaints were investigated: 1) that the facility did not ensure residents' rooms were kept clean, safe, and sanitary, which was found to be unfounded; 2) that facility staff were not meeting residents' care needs, which was found to be unsubstantiated. No citations or deficiencies were issued.

The investigation included interviews with staff, residents, and facility leadership, as well as observations of resident rooms and review of records. The allegations regarding cleanliness and care needs were found to be unfounded or unsubstantiated, with no deficiencies or citations noted during the investigation.

The inspection found no deficiencies. The facility was observed to be in compliance with all applicable regulations, including safety equipment, food storage, and environmental conditions.

Complaint investigation 26-AS-20240613120601 was conducted. The deficiency was substantiated as the facility did not provide requested documentation for resident R1 who moved away on June 16, 2024.

The facility failed to provide requested documentation related to resident R1's admission agreement and notification of rate increases. The only documentation available for R1 was the physician's report, care plan, and assessment. This deficiency poses a potential risk to the health, safety, or personal rights of persons in care.

The Licensing Program Analyst toured the memory care unit, tested exit doors and courtyard gate security, observed the locked medication room with two med carts, and reviewed staff in-service training logs from July to October 2025. No citations were noted during this visit.

The complaint alleged that staff were not following emergency disaster plan procedures during a power outage on June 11-12, 2024. The investigation included interviews with witnesses, residents, staff, and review of incident reports and facility procedures. The complaint was determined to be unfounded.

The investigation found the allegations to be unfounded after interviews with staff, residents, and review of documentation showed that staff conducted regular safety checks during the power outage and residents did not report any issues or discomfort.

The visit was complaint-related, investigating allegations from complaints received on 2024-10-17, 2024-06-13, and 2025-06-12. The Licensing Program Analyst determined that the allegations require further investigation and no deficiencies were cited at this time.

No deficiencies were cited at this time as the allegations require further investigation. The LIC 500 form was noted to need updating along with the current staff list.

The Licensing Program Analyst toured the memory care unit, tested delayed egress doors, reviewed resident check-in/out logs, memory care exit door logs, and staff training logs. No citations were noted during this visit.

The Licensing Program Analyst toured the memory care unit, tested delayed egress doors, reviewed resident check-in/out logs, memory care unit exit door logs, and staff training logs. No citations were noted during this visit.

The complaint investigation was initiated due to a complaint received on 2025-03-04. The investigation concluded on 2025-05-23, but the complaint was not closed due to the need for additional information. The visit on 2025-06-12 was to amend the report, and the findings remain unsubstantiated.

The findings of the allegations remain unsubstantiated, and no deficiencies were cited during this visit. The report was reviewed with the Assisted Living Director, Jmy Ramos, and a signed copy was provided.

The Licensing Program Analyst conducted interviews with the Executive Director, residents, and staff, reviewed the resident's physician report and service plan, and toured the facility. The resident was found without injuries. The case requires further investigation.

The visit was triggered by a complaint/incident report about a memory care resident found outside the building. The resident was escorted back by another resident and staff, and no injuries were observed.

The Licensing Program Analyst interviewed the Executive Director, residents, and staff, reviewed the resident's physician report and service plan, and toured the facility. The resident was found without injuries. The case requires further investigation.

The complaint alleging lack of hot water was substantiated based on interviews with residents, staff, and facility administration, as well as document review. The water heater was out of service from May 16 to May 20, 2025, and no alternative arrangements were made for residents to bathe with hot water.

The investigation found that the water heater was malfunctioning from May 16 to May 20, 2025, and the facility did not provide any alternative options for residents to have hot water during this period. The allegation was substantiated.

The complaint included allegations of poor food quality, failure to follow a resident's admission agreement related to transportation, and inadequate provision of activities. Interviews with residents and staff, document reviews, and observations were conducted. The facility was found to be actively addressing transportation issues and staff training for activities. The complaint was unsubstantiated.

The investigation found that although some issues were noted, such as food temperature concerns and lack of experienced staff conducting activities, there was insufficient evidence to substantiate the allegations. No deficiencies were cited, and the allegations were determined to be unsubstantiated.

The complaint included allegations that staff served food not of quality, did not follow a resident's admission agreement, and failed to ensure activities were provided. Interviews with residents and staff, observations, and document reviews were conducted. The allegations were found unsubstantiated due to lack of preponderance of evidence.

The investigation found that while some issues such as food temperature and activity provision were noted, there was insufficient evidence to substantiate the allegations. The facility was actively addressing staffing challenges and had trained staff for activities and food handling. No deficiencies were cited.

The visit was complaint-related, investigating an incident between two residents. Based on interviews and review, no prior altercation was found, and the incident was the first between the residents. Physician reports indicated R2 has verbal aggressive behavior, while R1 has no aggressive behavior. No substantiation status was explicitly stated.

The investigation found that resident R2 pushed resident R1 without reason, causing R1 to fall. Staff intervened immediately, and care plans for both residents were updated. Staff received training on abuse prevention and managing aggressive behavior. No citations were issued during this visit.

The visit was triggered by a complaint incident report received on May 20, 2025 regarding a medication error for Resident R1. The complaint was substantiated as the medication error was confirmed during the investigation.

The investigation confirmed that Resident R1 erroneously received a 50 mg dose of medication M1 despite a physician's order to reduce the dose to 25 mg. This posed an immediate health, safety, and personal rights risk. An in-service training was provided to staff on May 17, 2025 to address the issue. A Type A deficiency was issued for failure to meet personnel requirements.

The visit was complaint-related due to an incident where resident R2 pushed resident R1 causing injury. The case is still under further investigation and no substantiation status is provided.

The report details that resident R2 pushed resident R1 without reason causing R1 to fall and be sent to the hospital. The Licensing Program Analyst interviewed the Executive Director, residents, and staff, and requested physician reports and service plans. The case requires further investigation.

The Licensing Program Analyst toured the memory care unit, tested egress doors which had auditory alarms, and reviewed requested documentation for staff in-service training. No deficiencies were cited per California Code of Regulations, Title 22.

The complaint alleged inadequate supervision by staff leading to resident falls and inadequate cleaning and sanitation of the facility. The investigation included interviews with staff and family members, review of resident service plans, physician reports, and incident reports. The findings were unsubstantiated for supervision issues and unfounded for cleaning issues, meaning no evidence supported the allegations.

The investigation found the allegations to be unsubstantiated and unfounded. The Department reviewed records, interviewed staff and family members, and observed the facility, concluding there was no evidence that staff failed to provide adequate supervision or proper cleaning and sanitation. No citations were issued.

The Licensing Program Analysts toured the facility, including resident bedrooms, Memory Care unit, dining and kitchen areas, and outside exits. They reviewed resident and staff records and found them complete. No deficiencies were cited during this inspection.

No deficiencies were cited per California Code of Regulations, Title 22. The licensing analysts toured the memory care unit, tested delayed egress doors, and reviewed staff in-service training summaries.

The complaint investigation was substantiated for failure to notify the resident's power of attorney about the increased level of care and rate increase. Other allegations about scabies outbreak notification, electric wheelchair use denial, and understaffing were unsubstantiated.

The investigation substantiated the allegation that the facility failed to notify the resident's power of attorney about the increased level of care and resulting rate increase, citing a deficiency. The allegations regarding failure to notify family of a scabies outbreak, denial of electric wheelchair use, and understaffing in the memory care unit were unsubstantiated.

The visit was triggered by a complaint incident report regarding a resident who eloped from the facility on August 20, 2024. The complaint was substantiated by findings of staff failure to conduct required supervision and head counts.

The facility staff failed to conduct required head counts/welfare checks during shift changes, resulting in a resident with neurocognitive disorder eloping from the memory care unit. An immediate civil penalty was issued for a repeat violation related to absence of supervision.

The complaint investigation was unsubstantiated for allegations that the resident did not feel safe or comfortable, the facility did not provide transportation to medical appointments, and staff neglected the resident's hygiene. The complaint was unfounded for allegations that the facility held the resident against their will and violated the resident's personal rights by denying participation in group outings.

The investigation found all allegations to be unsubstantiated or unfounded based on interviews, record reviews, and observations. No deficiencies were cited under California Code of Regulations, Title 22. The facility was found to have operable telephones, provide transportation within a 12-15 mile radius with billing for longer distances, and staff did not neglect resident hygiene. The resident was not held against their will and was allowed to participate in group outings.

The complaint investigation was conducted following allegations of medication mishandling, a norovirus outbreak, visitor refusal, and discomfort with male caregivers. The findings were that the medication mishandling and norovirus outbreak allegations were unfounded, and the visitor refusal and caregiver gender preference allegations were unsubstantiated.

The investigation found no evidence to support the allegations. The medication mishandling complaint was unfounded as medication administration followed physician orders. The facility had only one norovirus case, which was reported and treated, so no outbreak occurred. Allegations of staff refusing visitors were unsubstantiated, with no evidence staff forced visitors to leave. The resident's discomfort with a male caregiver was also unsubstantiated, with the facility accommodating gender preferences after a formal request.

The complaint alleged that facility staff did not properly notify a resident of a rate increase. The investigation included interviews with the Executive Director, Business Office Director, and the resident, as well as review of documents including the resident's account ledger and notices of rate increase. The complaint was found to be unfounded.

The investigation found that the resident did not receive the original 60-day notice of rate increase issued in October 2023, but the facility subsequently issued a new 60-day notice dated 2024-08-23, which the resident signed. The resident continued to receive services without disruption and agreed to pay the new rate starting 2024-11-01. The allegation was determined to be unfounded.

The complaint involved a resident who eloped from the facility on August 20, 2024. The incident was reported on August 26, 2024. Staff conducted a census and local law enforcement returned the resident to the facility. The complaint investigation was ongoing with no substantiation or deficiencies cited yet.

The Licensing Program Analyst determined that the incident required further investigation but no deficiencies were cited at this time according to California Code of Regulations Title 22.

The complaint alleged that the facility call system was in disrepair. The investigation included interviews with residents and staff, review of documents including resident rosters and call bell system invoices, and observation of the call system functionality. The allegation was found to be unsubstantiated.

Based on interviews with residents and staff, document reviews, and observations, there was insufficient evidence to substantiate the allegation that the call system was in disrepair. No deficiencies were cited during the visit.

The visit was triggered by an incident report received on August 26, 2024, regarding resident R1 who eloped from the facility on August 20, 2024. Staff conducted a census and local law enforcement found the resident outside the facility. Interviews and record reviews were conducted, and the incident was determined to require further investigation with no deficiencies cited.

The Licensing Program Analysts conducted interviews and reviewed documentation related to the incident. No deficiencies were cited at this time as per California Code of Regulations Title 22, but the incident requires further investigation.

The Licensing Program Analyst reviewed staff in-service training summaries conducted from 04/23/2024 to 07/30/2024 on various topics including elopement, skin breakdown monitoring, reporting change of condition, fall reduction, heat illness prevention, and fire safety. No deficiencies were cited per California Code of Regulations, Title 22.

The complaint alleged staff physically abused a resident (R1) on April 15, 2024. Local Law Enforcement responded to the incident and interviewed staff and the resident. Staff denied abuse and described the resident as agitated and physically aggressive. Residents interviewed did not recall the incident and stated staff were nice. The resident's medical and incident reports indicated agitation and aggressive behavior. The complaint was determined to be unfounded.

The investigation included interviews with staff, residents, and review of incident and medical reports. The department found the allegations to be unfounded, meaning the allegations were false, could not have happened, or lacked a reasonable basis. No deficiencies were cited.

The complaint alleged that the facility's temperature was not within the required range and that the ventilation system was not working, causing odor. After investigation, including resident interviews and facility maintenance reviews, the allegations were found unsubstantiated.

The investigation found the allegations unsubstantiated after interviews, record reviews, and multiple unannounced visits. No foul odors were detected from the ventilation system, and the heating issue in one resident's room was resolved promptly without further deficiencies cited.

The facility has serious violations and a noncompliance conference was held where compliance plans were established. The facility will begin a 2-year monitoring plan with more frequent licensing inspections, and legal consultation may result in administrative actions such as Administrator De-Certification, License Revocation, or Employee Exclusion.

The complaint investigation was substantiated regarding transportation services; residents were asked to cancel or reschedule medical appointments due to lack of transportation. The complaint about inadequate meals and food supply was unsubstantiated.

The investigation substantiated that the facility failed to provide or arrange transportation for medical appointments when no driver was available, causing residents to cancel or reschedule appointments. The facility has since hired a driver. Another complaint regarding inadequate meals and food supply was unsubstantiated.

The complaint investigation was substantiated. Allegations included staff neglect causing multiple fractures to a resident, inadequate staffing to meet residents' needs, and failure to submit incident reports. The resident sustained injuries from falls and altercations with other residents. The facility failed to report incidents timely and did not reappraise the resident after injuries. A civil penalty of $500 was assessed with additional penalties pending.

The investigation substantiated that a resident (R1) with motor impairment and neurocognitive disorder sustained multiple injuries including fractures and bruises due to falls and altercations with other residents. The facility failed to submit required incident reports and did not reappraise the resident after injuries. Staffing and supervision were inadequate to meet the resident's needs. Deficiencies were cited and a civil penalty was assessed.

The complaint contained two allegations: inadequate staffing to meet residents' needs and lack of planned activities. Interviews with the Executive Director, staff, and residents, as well as document reviews, showed sufficient staffing and planned activities. The complaint was found unsubstantiated.

The investigation found that the facility generally maintained adequate staffing levels with some periods of one care staff covering both memory care and assisted living units, and that residents' needs were met. The facility also had a full-time Activities Director and offered a variety of planned activities, although not all residents were interested in participating. The allegations were determined to be unsubstantiated.

The complaint was substantiated. The resident wandered away from the facility due to lack of supervision. The resident has a dementia diagnosis and requires 24-hour supervision. The resident left the facility unassisted at 11:30 pm, outside the caregiver's shift, and was found by law enforcement.

The investigation found that on 2021-10-08, a resident with dementia left the facility unassisted at 11:30 pm, outside the 1:1 caregiver's shift hours, and was found by law enforcement. The allegation was substantiated based on interviews, records, and review of the resident's condition indicating a need for supervision.

The complaint involved four reported theft incidents affecting residents R1 through R4. The residents and responsible parties were aware, and the facility took steps including police notification and resident meetings. The complaint was investigated with no deficiencies found.

Four incidents of theft involving residents were reported between 02/28/2023 and 03/13/2023. The facility reported the incidents to police and Ombudsman, held a town hall meeting to address the issue, recommended securing valuables, and provided lockboxes to some residents. No deficiencies were cited per California Code of Regulations, Title 22.

Four incidents of theft were reported between 02/28/2023 and 03/13/2023 involving residents R1 to R4. The facility reported the incidents to police and Ombudsman, held a town hall meeting to address the issue, and provided lockboxes to some residents. No deficiencies were cited during the inspection.

The inspection found the facility generally compliant with no citations noted. Observations included locked medication and cleaning product rooms, sufficient food and PPE supplies, proper room temperatures, and functional fire safety equipment. Some handwashing posters were missing but the administrator committed to placing them within 7 days.

The complaint alleged that a resident was physically abused while in care. The investigation included interviews with the Executive Director, Memory Care Director, the resident, and the resident's family member. The resident confirmed being threatened but not physically harmed. The family member could not confirm the incident due to the resident's history of similar allegations at another facility. The allegation was found unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation of physical abuse. Interviews and assessments revealed no bruising or signs of injury, and the resident had a history of similar allegations at a previous facility. The allegation was determined to be unsubstantiated.

The facility was found to have adequate infection control measures including screening, PPE supplies, hand sanitizer stations, and signage. No deficiencies were cited during the visit per California Code of Regulations, Title 22.

The Licensing Program Analyst conducted a virtual tour and provided recommendations including posting mask signage at the entrance, posting hand washing signage near sinks, and utilizing foot operated trash cans in various areas of the facility.

The facility was observed to be in good repair with all required furnishings and safety features. No deficiencies were noted during the inspection, and the physical plant is recommended for licensure pending completion of application documents.

The applicant and administrator successfully completed Component II of the licensing process, confirming understanding of facility operation, staff qualifications, program policies, and application document requirements.