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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202518
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:22:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/31/2024 01:22 PM - 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:ALEXANDRIA VICTORIAFACILITY NUMBER:
445202518
ADMINISTRATOR:JOHN GRYSPOS, JR.FACILITY TYPE:
740
ADDRESS:226 MORRISSEY BOULEVARDTELEPHONE:
(831) 429-9137
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:13CENSUS: 8DATE:
05/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John Gryspos Jr.TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation visit and met with Administrator John Gryspos Jr.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed the first aid kit and found it to be complete.

LPA Marrufo toured 11 out of 11 resident bedrooms. Each bedroom had functioning lights and available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in the bedrooms and hallways and found them to function properly when tested.

LPA Marrufo observed the resident bathrooms and found them to have functioning lights and available soap and paper towels. The bathroom water temperatures were measured at 119 F and 107 F.

LPA Marrufo reviewed the Centrally Stored Medication Logs and the resident and staff records. Resident R1's Physician's Report indicated R1 is diagnosed with dementia and the most recent Physician's Report was from 2021.

LPA Marrufo toured the outside area and found the exits to be clear of obstructions.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrator John Gryspos Jr. and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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Document Has Been Signed on 05/31/2024 01:22 PM - It Cannot Be Edited

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: ALEXANDRIA VICTORIA
FACILITY NUMBER: 445202518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
87705(c)(5)

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87705(c)(5) Care of Persons with Dementia: c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as
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Licensee agrees to submit an updated medical assessment (Physician's Report) for resident R1 and any other residents with dementia who have medical assessments that are over a year old to CCL by POC date.
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specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Licensee did not ensure resident R1 with dementia had a Physician's Report that is annually updated.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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