445202518-2-18-2025-26-AS-MTAN-DDZUZ2-20250218150049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202518
Report Date: 02/18/2025
Date Signed: 02/18/2025 03:01:03 PM

Document Has Been Signed on 02/18/2025 03:01 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 VICTORIA		FACILITY NUMBER:	445202518
ADMINISTRATOR/ DIRECTOR:	JOHN GRYSPOS, JR.		FACILITY TYPE:	740
ADDRESS:	226 MORRISSEY BOULEVARD		TELEPHONE:	(831) 429-9137
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY: 13	TOTAL ENROLLED CHILDREN: 0	CENSUS: 7	DATE:	02/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Administrator John Gryspos,Jr.		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced at 9:35AM to conduct a Required- 1 Year annual inspection and met with Administrator (ADM) John Gryspos, Jr. ADM states the facility has 7 residents. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. Facility thermostat temperature display was observed at 70 degrees F. All exit and passageways were free and clear of obstruction.

LPA observed 4 residents in the dining room eating breakfast and watching TV, with 2 staff members serving breakfast and talking to residents.

LPA toured 11 resident bedrooms. 11 out of 11 resident bedrooms have a bed, functioning lights, dresser/table, a chair, bedding and space for personal belongings. LPA toured 7 resident bathrooms. 7 out of 7 resident bathrooms have hand soap, paper towel, functioning lights, and covered trash bins. LPA measured water in 7 resident bathrooms with a temperature range from 105 to 112 degrees F.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed knives and cleaning product storage area as locked and inaccessible to residents in care. LPA observed the medication storage area in the living room as locked and inaccessible to residents in care.

LPA reviewed 5 resident records. 5 out of 5 resident records were found to be complete. Resident records included emergency contact information, physician’s report, appraisal/needs and service plans, and personal rights.

See LIC809C

Jin Jackie	TELEPHONE: (714) 319-3786
Marcella Tarin	TELEPHONE: (714) 328-5152
	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

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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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
	VISIT DATE: 02/18/2025

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All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 8/8/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was conducted on 2/12/2025.

LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). 4 out of 5 CSMDR’s were observed to be complete with all medication documented. LPA observed Resident R2's CSMDR prescription medications fill date was not current. ADM updated R2's prescription medication fill dates during inspection. LPA advised ADM to ensure all resident's CSMDRs are documented and recorded accurately.

LPA reviewed 5 staff records. 5 out of 5 staff records were found to be complete. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record and staff training.

ADM provided LPA with an updated copy of Administrator Certificate.

No deficiencies cited during today's visit per California Code of Regulation Title 22. A Technical Violation was issued during today's visit. An exit interview was conducted with ADM John Gryspos, Jr and a copy of this report was provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC809 (FAS) - (06/04)

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