<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202625
Report Date: 03/08/2025
Date Signed: 03/08/2025 12:10:50 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
06/06/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220606150324
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:
11:30 AM
MET WITH:John Gryspos TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents sustained injuries/infections while in care
Staff did not seek timely medical care for resident in care.
Staff did not report resident incidents to appropriate parties
Staff did not follow resident's care plan
Staff do not provide proper incontinence care to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 resident sustained injuries while in care, staff did not seek timely medical care for the resident in care, and staff did not report resident incident to appropriate parties. This investigation involved interviews with facility staff and residents. Based on the interviews, 5 out of 5 staff members denied the allegations. LPA interviewed 2 out of 2 residents, both of whom stated that they feel safe and receive medical care when needed. A review of the records revealed no documentation indicating that Resident 1 (R1) and Resident 2 (R2) sustained injuries.

Continued LIC 9099-C
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-20220606150324
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Furthermore, R1 denied the allegations. LPA Lee was unable to obtain a statement from R2, as R2 refused to be interviewed. Due to the lack of documentation and insufficient information, there was no clear indication that the alleged incidents occurred. Based on the interviews and records review during the investigation, LPA Lee was unable to corroborate the allegations.

Additionally, it was alleged that staff did not follow resident’s care plan and staff do not provide proper incontinence care to resident in care. This investigation also involved interviews with facility staff and residents. 5 out of 5 staff members denied the allegations. LPA interviewed 2 out of 2 residents; both of whom stated they receive incontinence care from the facility staff. In an interview with R1, R1 confirmed receiving 1:2 assistance with transferring. A review of R1’s LIC 602 Physician’s Report does not indicate the need for 1:2 assistance; however, R1's LIC 625 Needs and Services Plan states that R1 requires 1:1 assistance if using a Hoyer lift or 1:2 assistance if using a person lift. According to R2’s LIC 602 Physician’s Report and LIC 625 Needs and Services Plan, R2 does not require 1:2 assistance. Based on facility notes, residents' briefs are being checked and changed as needed. Based on the interviews and records review during the investigation, LPA Lee 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
06/06/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220606150324

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:
11:30 AM
MET WITH:John Gryspos TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not properly maintain resident's medication records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 staff did not properly maintain resident’s medication records. The investigation involved reviewing relevant documentation. On 11/23/24, LPA Lee conducted a review of the medication records for three residents and observed the following:

• Resident 1 (R1): Several medications documented on the Medication Administrator Record (MAR) log but were not present in R2’s medication box. Conversely, medications found in R2’s medication box were listed on the LIC 622 Centrally Stored Medication and Destruction Record (CSMD) but were not reflected on the MAR log alongside the other medications. Furthermore, R2’s medications were not initialed as administered on 11/22/24. The CSMD did not match the MAR log. Additionally, some medications were listed on the MAR log but were missing from the CSMD records.
• Resident 2 (R2): Three medications were listed on the MAR logs; however, they were not present in the facility. Several medications were not initialed to indicate administration, and the CSMD did not align with the MAR log. Additionally, multiple medications were listed on the MAR log but were not documented on the CSMD. Medications observed in R1's medication box were not listed on the MAR log, though they were found in the CSMD.

• Resident 3 (R3): Medications found in the resident’s medication box were not listed on the MAR log, though they were recorded on the CSMD. Also, medications on the MAR log were not present in the medication box. The Med-tech explained that the missing medications were discontinued; however, the MAR log did not reflect this discontinuation.
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 administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
Continued 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-20220606150324
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Furthermore, R2’s medications were not initialed as administered on 11/22/24. The CSMD did not match the MAR log. Additionally, some medications were listed on the MAR log but were missing from the CSMD records.

• Resident 2 (R2): Three medications were listed on the MAR logs; however, they were not present in the facility. Several medications were not initialed to indicate administration, and the CSMD did not align with the MAR log. Additionally, multiple medications were listed on the MAR log but were not documented on the CSMD. Medications observed in R1's medication box were not listed on the MAR log, though they were found in the CSMD.
• Resident 3 (R3): Medications found in the resident’s medication box were not listed on the MAR log, though they were recorded on the CSMD. Also, medications on the MAR log were not present in the medication box. The Med-tech explained that the missing medications were discontinued; however, the MAR log did not reflect this discontinuation.

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 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-20220606150324
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
03/22/2025
Section Cited
CCR
87465(a)(6)
1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility…
(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 evidence by:
1
2
3
4
5
6
7
Facility Administrator stated that a review of the section, 87465(a)(6), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the
8
9
10
11
12
13
14
Based on observation and record reviews the Licensee did not ensure the residents MAR logs and CSMD was not accurately documented to reflect resident’s medications. This posed a potential health, safety, and personal rights risks to
8
9
10
11
12
13
14
cited section will 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.

1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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