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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202625
Report Date: 03/08/2025
Date Signed: 03/08/2025 12:00:26 PM

Unsubstantiated


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
06/08/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220608143013
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: 6DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:John GrysposTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility does not have adequate food supplies
INVESTIGATION FINDINGS:
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On at 03/08/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator John Gryspos and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 6. A brief interview with conducted with the administrator.

It was alleged that facility does not have adequate food supplies. This investigation consisted of observations and interviews with facility staff. On 11/23/24 facility visit, LPA Lee observed sufficient 2 days perishable supplies and 7 days nonperishable of food supplies in the facility. Furthermore, during today LPA Lee also observed sufficient 2 days perishable and 7 days nonperishable of food supplies. In an interview with administrator John Gryspos groceries are done every Saturday of the week.

Continued LIC
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20220608143013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/08/2025
NARRATIVE
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 LPA Lee interviewed 2 out of 2 resident who stated that they have no concerns that the facility does not have adequate food supplies. Based on the interviews conducted during the investigation process LPA was unable to corroborate the allegations.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.
A copy of this report was provided. Exit interview.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/08/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220608143013

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: 6DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:John GrysposTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not receive required trainings.
INVESTIGATION FINDINGS:
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On at 03/08/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator John Gryspos and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 6. A brief interview with conducted with the administrator.

It was alleged that staff did not receive required trainings. This investigation consisted of records reviewed and interviews with staff. On 11/23/24 LPA Lee reviewed 3 out of 4 facility staff files and they were incomplete. Two of the facility staff files did not have 20 hours of continual trainings.1 out of 4 staff did not have a current first aid/CPR. It was learned that staff 1 (S1) first aid/CCR had expired on 10/27/24 and renewed on 11/30/24 and emailed to LPA Lee 12/01/24. In an interview with administrator John Gryspos LPA Lee was informed that S1 didn’t have a current first aid/CPR.

LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20220608143013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/08/2025
NARRATIVE
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 Moreover, in an interview with administrator facility staff has completed their required trainings and first aid/CPR; however, the documents were not in staff files during the visit.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with the administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220608143013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2025
Section Cited
CCR
1569.625(b)
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1569.625 Staff training; legislative findings; contents
(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training….

This requirement is not met as evidence by:
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Facility Administrator stated that a review of the section cited will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will
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Based on observation and record reviews the Licensee did not ensure 3 facility staff had 20 hours of continual education training and first aid/CPR current. This posed a potential health, safety, and personal rights risks to
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be completed and submitted to the LPA’s email at pang.lee@dss.ca.gov by the due date of 03/22/25 COB at 5:00pm. Information submitted must include. Attendees, trainers, and information discussed.

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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5