445202625-5-22-2024-26-AS-JJIN-D5VUBT-20240603152649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202625
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:02:59 PM

Substantiated

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
04/12/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240412084701

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:	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Adrian Mendoza		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner
Facility staff spoke inappropriately to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Adrian Mendoza. The Department conducted an initial complaint investigation on 04/19/2024. During visit, LPA Marrufo interviewed resident R1-R4, Staff S1-S5, and 4 individuals who are emergency contacts of R1-R4. LPA Marrufo also conducted a telephone interview with the Conservator (C1) of former resident R5, who now resides at another facility. On 04/26/2024, LPA Marrufo conducted an interview with R5 at R5’s current licensed residential care facility.

During interviews on 04/19/2024, Resident R3 stated that a female staff with black hair handled R3 roughly when attempting to transfer R3 from R3’s bed. R3 stated to have told the staff to “take it easy” on R3, but the female staff ignored R3. Resident R4 stated that a female staff turned R4 over in bed in a rough manner.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 3

Control Number 26-AS-20240412084701

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: 05/22/2024

NARRATIVE

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Residents R1-R2 stated to have not observed a staff handle residents in a rough manner or observed a staff speak inappropriately to residents.

During interview on 04/26/2024, resident R5 stated that a female staff would push R5 against a wall whenever R5 defecated in R5’s pants. R5 stated the female staff would say “nasty” because R5 had defecated in R5’s pants. R5 stated the female staff would push R5 against a wall about 3 times per week while R5 was living at the facility. R5 stated the female staff would spray an aerosol spray bottle at R5. R5 also stated to have observed the same female staff roughly feeding another resident. R5 stated the female staff would “slobber” the food all over the resident.

Residents R3, R4, and R5 could not provide a name or any further descriptions of the female staff.

During interviews on 04/19/2024, staff S1-S5 and the 4 emergency contacts of Residents R1-R4 stated to have not observed any staff handle residents in a rough manner or speaking inappropriately to residents. Staff S1-S5 each denied having treated residents in a rough manner or speaking inappropriately to residents. C1 stated that R5 reported to C1 that a female staff pushed R5 against a wall when R5 defecated R5’s pants and said “nasty.”

Deficiencies were cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

This report was reviewed with Adrian Mendoza and a copy of the report and appeal rights were provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240412084701

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: 05/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/23/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1(a)(3) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive	1 2 3 4 5 6 7	Licensee agrees to submit a plan to CCL by POC date to conduct in-service training with all staff covering the Personal Rights of Residents in All Facilities, including ensuring residents are free from punishment, humiliation, intimidation, or
	8 9 10 11 12 13 14	nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Licensee did not ensure that a female staff did not handle residents roughly, including by pushing R5 against a wall when changing R5, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	abuse, or other actions of a punitive nature. Once in-service trainings are complete, Licensee agrees to submit copies of training records to CCL.
Type A 05/23/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Licensee agrees to submit a plan to CCL by POC date to conduct in-service training with all staff covering the Personal Rights of Residents in All Facilities, including according dignity to residents in their personal relationships with staff,
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee did not ensure that a staff did not treat a resident without dignity by saying “nasty” when changing a resident, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	residents, and other persons. Once in-service trainings are complete, Licensee agrees to submit copies of training records to CCL.

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

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