445202518-5-8-2024-26-AS-KHOS-D6JLTS-20240624090250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202518
Report Date: 05/08/2024
Date Signed: 05/08/2024 05:47:03 PM

Unfounded

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
05/07/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240507105422

FACILITY NAME:	ALEXANDRIA VICTORIA		FACILITY NUMBER:	445202518
ADMINISTRATOR:	JOHN GRYSPOS, JR.		FACILITY TYPE:	740
ADDRESS:	226 MORRISSEY BOULEVARD		TELEPHONE:	(831) 429-9137
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	13	CENSUS: 10	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adrian Mendoza and John Gryspos Jr Administrators		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not ensure bathroom is cleaned properly
Staff do not ensure the shower mat would not slip
Staff do not ensure residents linens are clean
Staff did not ensure residents door seal was fixed properly

INVESTIGATION FINDINGS:

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On 5/8/2024, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannouced complaint investigation and met with the facility administrator Adrian Mendoza and John Gryspos. LPA stated the purpose of the visit is to address a complaint that was received on 5/7/2024.

This agency has investigated the complaint alleging, bathroom is not cleaned properly, staff do not ensure the shower mat would not slip, lines are not clean, door seal was not fixed properly. LPA found that the complaint was unfounded the individual does not reside in the facility.

No deficiencies are cited during today's visit. An exit interview was conducted with Administrator John Gryspos. A copy of the report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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