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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202625
Report Date: 05/08/2024
Date Signed: 05/08/2024 06:06:48 PM


Document Has Been Signed on 05/08/2024 06:06 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 2FACILITY NUMBER:
445202625
ADMINISTRATOR:GRYSPOS JR, JOHNFACILITY TYPE:
740
ADDRESS:228 MORRISSEY BLVDTELEPHONE:
(831) 429-9137
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:8CENSUS: 5DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:John Gryspos, Jr. and Adrian MendozaTIME COMPLETED:
06:10 PM
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Licensing program analyst, (LPA) Maria Mita Partoza, conducted an unannounced case management for the incident that was reported on 4/2/2024. LPA was met by one of the administrator Adrian Mendoza (ADM1) and Administrator John Gryspos (ADM 2) arrived at around 3:00 p.m.

LPA and ADM toured the facility inside and outside including but not limited to kitchen, laundry room, resident's room and bathroom, living room and dining room. The property has 3 garden rooms separated from the two building. LPA walked the exterior and the back alley way. LPA observed that walkways and alley ways are free from obstruction. The kitchen was sanitary and organized, toxics and chemicals are locked in a secure area.

Residents and visitors can access the back alley way from the facility into the street. ADM 2 stated that the back gate has a chime when accessed. ADM 2 stated that when a resident is ambulatory and able to access the back alley gate, the resident has a GPS tracker.

The back alley ways is used as an entrance for people who are non-ambulatory, it is used as a loading for non-amublatory residents and for delivery of good. ADM stated that all visitors are to go through the main door at 226 Morrissey Blvd. to sign in and out.

The back alley has a door bell that needs to be rang in order for the facility to let people in the building who are visiting family. ADM stated that the door bell can be used by visitors and park at the back of the building if the visitors are non-ambulatory or has a hard time using the front door steps of the main building (226).
ADM 1 stated that all visitors are required to sign in and out of the prior to seeing a family member. ADM 1 stated that visitors coming from the back gate needs to sign in as well.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (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.

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 2
FACILITY NUMBER: 445202625
VISIT DATE: 05/08/2024
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LPA interviewed 3 residents (R1 to R3) and 4 staff including 2 administrator. This case management will remain open for further investigation of the incident reported on 4/2/2024.

No deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM 2 John Gryspos, Jr. and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (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
LIC809 (FAS) - (06/04)
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