445202625-7-23-2024-26-AS-JJIN-D8EVSA-20240823164112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202625
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:06:02 AM

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
05/08/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240508170809

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:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	John Gryspos Administrator		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff do not ensure bathroom is cleaned properly
Staff do not ensure the shower mat would not slip
Staff did not ensure residents door seal was fixed properly

INVESTIGATION FINDINGS:

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On 7/23/2024 at 8:45 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the findings for the complaint received by the department on 5/8/2024 alleging that the facility did not ensure that the bathroom is cleaned properly, the shower non- skid mat does not slip and resident's door seal is not fixed properly.LPA met with admininistrator (ADM) John Gryspos and (DADM) Adrian Mendoza and stated the purpose of the visit.

During the visit on 5/8/2024 at 1:05 p.m. LPA observed the open area of the bathroom was organized and was recently scrubbed and washed. However, LPA observed the following in the shower area: The shower curtain has stain at the bottom, a detangled wire hanger and a mop leaning on the wall did not have a non-skid mat on the shower floor. The bathroom shower area has a brown stain on the right side wall close to the floor and a commode with the pail was sitting on top of the seat has brown color residue. ADM stated the staff is the process of cleaning the facility after the meals were served.
page 1 of 2 see LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 5

Control Number 26-AS-20240508170809

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: 07/23/2024

NARRATIVE

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LPA with DADM toured the interior of the facility, including but not limited to the kitchen, dining, and 5 resident's bedroom (R1 to R5). LPA observed there are 6 rooms in the facility and one is vacant and is being renovated.

LPA observed that 4 out of 5 residents were non-ambulatory and 1 out of 5 is ambulatory. R1 to R5's bedroom were kept sanitary and free from obstruction and debris. Sliding door of each room are free from obstruction and easily opened. LPA observed the strip of door seal on R1s entry door frame was peeling off. ADM stated the door strip will be replaced.

LPA with ADM toured the front yard and observed no obstructions on walkways. The front yard and backyard grounds are constructed to drain the water away from the building structure.

Based on LPAs observation and interviews the preponderance of evidence standard has been met, therefore the above allegation(s) were found to be substantiated based on California Code of Regulation (CCR) Title 22, Division 6, Chapter 8, 87303 for Maintenance and Operation*. LPA discussed the deficiencies with the LIC/ADM. Correction were made at the time of the visit on 7/23/2024.

Deficiencies were cited during today's visit. See LIC 9099D. An exit interview was conducted with administrator (ADM) John Gryspos and designated administrator (DADM) Adrian Mendoza. A copy of the report and appeals rights were provided.

*87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition (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.

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20240508170809

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: 07/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/24/2024 Section Cited CCR 87303(1)(a)(e)(5)	1 2 3 4 5 6 7	87303 Maintenance & Operation (a)The facility... be clean...sanitary...for the safety of...residents, employees & visitors(1) Floor surfaces in bath... maintained (e)...fixtures...maintained (5)Non skidmats...used in ...showers. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ADM/Licensee stated the bathroom will be maintained, be kept in a sanitary condition, curtain will be changed and non-skid mats will be available for residents to use and the door seal will be repaired. ADM/Licensee will submit the plan of correction by the due date.
	8 9 10 11 12 13 14	Based on the observation the licensee did not maintain a clean, sanitary floors surfaces in the bathroom and did not have a non-skidmat in the shower area, the door seal was not attached to the door frame properly and was peeling off.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 3 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
05/08/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240508170809

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:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	John Gryspos Administrator		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff do not ensure residents linens are clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannouced visit to deliver the findings of the complaint received by the department on 5/8/2024 alleging staff do not ensure residents linens are clean. LPA met with administrator John Gryspos and stated the purpose of the visit.

Based on observation, LPA observed that the beddings, linens, and bedsheet was currently being washed by staff during the time of the visit on 5/8/2024.

Based on interview ADM stated that linens, bedsheets and beddings were brought in by the family of the resident (R1).. ADM stated that the beddings are washed once a week sometimes more if resident has problem with bladder incontinence or as often as necessary.

page 1 of 2
see LIC 9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20240508170809

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: 07/23/2024

NARRATIVE

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Based on interview with responsible parties (RP1 to RP4) for residents R1 to R5, the following statement are as follows:

RP1 stated to help R1 have familiarity with the new living space, the family have brought in personal items such as but not limited to bed sheets, pillows and pillow cases. RP1 stated the items are not new. RP1 stated that the facility will do laundry once a week or as often as necessary. RP1 stated the stains in the pillow cases were there prior to R1 moving in to the facility.

RP2, stated he/she is the responsible for two of the residents R2 and R3 who were admitted in 2020 and 2022. RP2 stated, he/she visit regularly, unannounced and observed the facility changes and washes linens and clothing on a regular basis and did not smell any foul odor when visiting.

RP3 stated, he/she is the responsible party for R4, and visits R4 on a regular basis, unannounced, and have no problem with the facility. RP3 stated he/she observed that bed linens are washed and changed regularly and as needed and did not smell any foul odor in R4s room.

RP4 stated, R5 was admitted at the facility in 2018. RP4 stated he/she visits R5 on a regular basis, unannounced and observed R5 bed linens are washed and changed on a regular basis and did not smell any foul odor in R5s room when visiting.

This agency has investigated the complaint alleging staff do not ensure the linens are clean. We have found the complaint was unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited. An exit interview was conducted with Administrator John Gryspos. A copy of the report was provided.

End of Report.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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