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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
445202625
Report Date:
02/14/2024
Date Signed:
02/14/2024 05:18:21 PM
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
ADMINISTRATOR:
GRYSPOS JR, JOHN
FACILITY TYPE:
740
ADDRESS:
228 MORRISSEY BLVD
TELEPHONE:
(831) 429-9137
CITY:
SANTA CRUZ
STATE:
CA
ZIP CODE:
95062
CAPACITY:
8
CENSUS:
6
DATE:
02/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:39 AM
MET WITH:
John Gryspos
TIME COMPLETED:
03:59 PM
NARRATIVE
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Licensing Program Analyst Steve Chang (LPA) conducted an unannounced annual inspection of the facility. LPA met with facility Administrator John Gryspos (ADM).
LPA observed 6 residents and 3 staff in the facility. Licensee, personal rights posters and ADM's administrator certificate were observed in the facility. LPA reviewed 3 resident files and 3 staff files.
LPA toured the facility including living room, kitchen, dining room, 4 restrooms and 6 single resident bedrooms. Knives cabinet was observed unlocked. Dish detergent cabinet under the sink was observed unlocked. No non-skid mats were observed in the bathroom/restrooms. Medication closet was observed locked. Room temperature was observed at 69 degree F, and hot water temperature was observed at 110 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.
The facility is equipped with smoke and carbon monoxide detectors and fire alarm detectors. One of the carbon monoxide detectors was observed out of battery. The fire extinguishers were observed on service on 08/01/2023. First Aid box, flash lights and night lights were observed in the facility. ADM stated the last time for the fire and emergency drill was on 8/1/2023.
All the bed rooms have the exits to outside of the building. The walkway on the left side of the building was observed having obstruction to remove. LPA toured the backyard with ADM. A living unit with address of 228A
MORRISSEY BLVD, Santa Cruz, CA. ADM stated the living unit is not in the scope of the facility. ADM stated the owner of the property lives in that living unit.
Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was reviewed with Administrator and a copy of the signed report was provided.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
6
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, and interview, the licensee did not comply with the section cited above in that one of carbon monoxide detectors was observed out of battery which poses an immediate health, safety risk to persons in care.
POC Due Date:
02/15/2024
Plan of Correction
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2
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4
Administrator stated he/she understands the importance of this issue and will submit a plan of correction by the POC due date. Administrator replaced the carbon monoxide detector's battery, tested it and it worked fine before LPA left the facility.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that dish washing detergent cabinet under the sink in the kitchen was observed unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/15/2024
Plan of Correction
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4
Administrator stated he/she understands the importance of this issue and will submit a plan of correction by the POC due date. Administrator put a lock for the cabinet that stores the dish washing detergent before LPA left the facility.
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that knives cabinet in kitchen was observed unlocked, which poses an immediate safety risk to persons in care.
POC Due Date:
02/15/2024
Plan of Correction
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2
3
4
Administrator stated he/she understands the importance of this issue, and will submit a plan of correction by the POC due date. Administrator put a lock for the knives cabinet to store knives before LPA left the facility..
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that there was no non-skid mat observed in the bathrooms, which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
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4
Administrator stated he/she understands the importance of this issue and will submit a plan of correction by the POC due date. Administrator put non skid mats in the facility bathrooms before LPA left the facility.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that the left side yard of the facility was observed with obstructions that was hard for people to walk through, which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
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Administrator stated he/she understands the importance of this issue and will submit a plan of correction by the POC due date. Administrator cleaned the stuff on the left side of the facility side yard before LPA left the facility.
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that two staff were observed without valid first aid certificate, which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
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2
3
4
Administrator stated he/she will submit a plan of correction by the POC due date to have staff to complete the first aid training and renew the first aid certificate.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that one staff was without the health screening record (LIC503) in the staff file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
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2
3
4
Administrator stated he/she will submit a plan of correction by the POC due date to have the staff to complete heath screening record.
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
02/14/2024 05:18 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
ALEXANDRIA VICTORIA 2
FACILITY NUMBER:
445202625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that 3 out of 3 residents' Centrally stored medication destruction records were not maintained up to date and inaccurate, which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
1
2
3
4
Administrator stated he/she will submit a plan of correction by the POC due date to maintain resident files up to date and accurate.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6