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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
445202518
Report Date:
07/26/2024
Date Signed:
07/26/2024 05:02:23 PM
Document Has Been Signed on
07/26/2024 05:02 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
FACILITY NUMBER:
445202518
ADMINISTRATOR/
DIRECTOR:
JOHN GRYSPOS, JR.
FACILITY TYPE:
740
ADDRESS:
226 MORRISSEY BOULEVARD
TELEPHONE:
(831) 429-9137
CITY:
SANTA CRUZ
STATE:
CA
ZIP CODE:
95062
CAPACITY:
13
CENSUS:
DATE:
07/26/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:
John Gryspos Jr.
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator John Gryspos Jr.
The purpose of the Case Management visit was to amend a prior complaint investigation report.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Administrator John Gryspos Jr. and a copy of this report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2024
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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