Alexandria Victoria 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct the facility's Required 1-Year inspection. LPA met with Administrator (ADM) John Gryspos Jr. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 35 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were purchased on 8/8/2024 and observed to be fully charged. The facility drill log was not available for review during inspection. ADM stated he would provide a copy of drills for 2025 to the CCL by 2/5/2026. ADM conducted an emergency drill with staff during the visit. LPA toured 6 residents rooms. All 6 resident rooms have a bed, functioning lights, and space for personal belongings. Page 1 of 2 LPA measured water temperature in 6 resident bathrooms with a range from 106.8 F to 111 F. LPA reviewed 4 resident files and 2 residents CSMDRs. LPA reviewed 4 staff files. LPA observed there were no staff training documents. ADM stated he was working on updating staff files and the training documents were not at the facility. ADM stated he would submit staff training documents to CCL by 2/5/2026. A Technical Violation was issued. LPA observed facility doors to have an auditory signal which alarmed in the facility kitchen dining area. LPA observed resident's sliding glass doors (located in resident rooms) did not alarm when opened by ADM. ADM stated he would have a third party vendor inspect the alarm system. A Technical Violation was issued. No deficiencies were issues during today's visit per California Code of Regulations, Title 22. A Technical Violation was issued. An exit interview was conducted with ADM and signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Feb 4, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: 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.

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 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. 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.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20220606150324

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Mar 22, 2025

(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: 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 tothe state’s words, verbatim · CDSS document, Mar 8, 2025

Plan of correction: 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 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.

Allegation investigated: Facility does not have adequate food supplies

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 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. 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.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20220608143013

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.625(b) · Plan of correction due date: Mar 8, 2025

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: 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 tothe state’s words, verbatim · CDSS document, Mar 8, 2025

Plan of correction: 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 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.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Annual Continuation visit and met with Administrator John Gryspos, Jr. This annual inspection is a continuation of the annual visit that was conducted on 2/18/2025. During today's visit, there are 6 residents and 2 caregivers. LPA reviewed 6 resident records. 5 out 6 resident records included physician's reports, needs and service plans, emergency contact information. Resident R4's physician report was incomplete. LPA advised ADM, prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice. LPA reviewed 6 staff records. 6 out of 6 staff records included medical assessments with TB results, California fingerprint clearance, and staff training. LPA reviewed 6 residents Centrally Stored Medication and Destruction Records (CSMDRs). 6 CSMDRs were documented accurately. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 8/8/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 2/12/2025. No deficiencies cited during today's visit per California Code of Regulations, Title 22. A Technical Assistance was issued, see LIC9102 for more information. An exit interview was conducted with ADM John Gryspos, Jr and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced at 3:05PM to conduct the facility's Required 1-Year annual inspection. LPA met with Administrator John Gryspos, Jr. ADM states the facility has 6 residents. LPA toured the facility's interior and exterior with the ADM, to include the dining room, kitchen, living room, resident bedrooms, and the front and back of facility. All exits and passageways were free and clear of obstruction. LPA toured the kitchen area, and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the digital thermostat on the refrigerator exterior door, refrigerator temperature at 35 degrees F and freezer at 0 degrees F. LPA observed knives and chemicals were locked in separate kitchen cabinets and inaccessible to residents in care. LPA observed a locked medication cart in the dining area, inaccessible to residents in care. LPA toured 6 resident bedrooms. 6 out of 6 resident bedrooms had a bed, clean bedding, a lamp, space for personal belongings, and a chair. Due to time constraints, this annual inspection will need to be continued at a later date. No deficiencies were issued during today's visit. An exit interview was conducted with Administrator, John Gryspos, Jr and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2025

Allegation investigated: 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

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 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. page 2 of 2 end of report 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. page 2 of 2the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 26-AS-20240508170809

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(1)(a)(e)(5) · Plan of correction due date: Jul 24, 2024

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: 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.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: 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.

Allegation investigated: Facility staff handled resident in a rough manner Facility staff spoke inappropriately to resident

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 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 REPORTthe state’s words, verbatim · CDSS document, May 22, 2024 · control 26-AS-20240412084701

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 23, 2024

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 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.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: 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 abuse, or other actions of a punitive nature. Once in-service trainings are complete, Licensee agrees to submit copies of training records to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 23, 2024

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. 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.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: 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, residents, and other persons. Once in-service trainings are complete, Licensee agrees to submit copies of training records to CCL.

Type of visit: Case Management - Incident

Licensing program analyst, (LPA) Maria Mita Partoza, conducted an unannounced case management for the incident that was reported on 4/2/2024. LPA was met by one of the administrator Adrian Mendoza (ADM1) and Administrator John Gryspos (ADM 2) arrived at around 3:00 p.m. LPA and ADM toured the facility inside and outside including but not limited to kitchen, laundry room, resident's room and bathroom, living room and dining room. The property has 3 garden rooms separated from the two building. LPA walked the exterior and the back alley way. LPA observed that walkways and alley ways are free from obstruction. The kitchen was sanitary and organized, toxics and chemicals are locked in a secure area. Residents and visitors can access the back alley way from the facility into the street. ADM 2 stated that the back gate has a chime when accessed. ADM 2 stated that when a resident is ambulatory and able to access the back alley gate, the resident has a GPS tracker. The back alley ways is used as an entrance for people who are non-ambulatory, it is used as a loading for non-amublatory residents and for delivery of good. ADM stated that all visitors are to go through the main door at 226 Morrissey Blvd. to sign in and out. The back alley has a door bell that needs to be rang in order for the facility to let people in the building who are visiting family. ADM stated that the door bell can be used by visitors and park at the back of the building if the visitors are non-ambulatory or has a hard time using the front door steps of the main building (226). ADM 1 stated that all visitors are required to sign in and out of the prior to seeing a family member. ADM 1 stated that visitors coming from the back gate needs to sign in as well. page 1 of 2 LPA interviewed 3 residents (R1 to R3) and 4 staff including 2 administrator. This case management will remain open for further investigation of the incident reported on 4/2/2024. No deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM 2 John Gryspos, Jr. and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst Steve Chang (LPA) conducted an unannounced annual inspection of the facility. LPA met with facility Administrator John Gryspos (ADM). LPA observed 6 residents and 3 staff in the facility. Licensee, personal rights posters and ADM's administrator certificate were observed in the facility. LPA reviewed 3 resident files and 3 staff files. LPA toured the facility including living room, kitchen, dining room, 4 restrooms and 6 single resident bedrooms. Knives cabinet was observed unlocked. Dish detergent cabinet under the sink was observed unlocked. No non-skid mats were observed in the bathroom/restrooms. Medication closet was observed locked. Room temperature was observed at 69 degree F, and hot water temperature was observed at 110 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. The facility is equipped with smoke and carbon monoxide detectors and fire alarm detectors. One of the carbon monoxide detectors was observed out of battery. The fire extinguishers were observed on service on 08/01/2023. First Aid box, flash lights and night lights were observed in the facility. ADM stated the last time for the fire and emergency drill was on 8/1/2023. All the bed rooms have the exits to outside of the building. The walkway on the left side of the building was observed having obstruction to remove. LPA toured the backyard with ADM. A living unit with address of 228A MORRISSEY BLVD, Santa Cruz, CA. ADM stated the living unit is not in the scope of the facility. ADM stated the owner of the property lives in that living unit. Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was reviewed with Administrator and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2024