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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 03/17/2021
Date Signed: 03/17/2021 03:16:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:FOREST HILLFACILITY NUMBER:
270700245
ADMINISTRATOR:ROSETTA W. CHANFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 45DATE:
03/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sarah EhretTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) David Marrufo and Steve Nguyen conducted an unannounced Case Management - Health and Safety visit and met with Executive Director Sarah Ehret. The purpose of the visit was to conduct a health and safety inspection of the facility.

During visit, LPAs Marrufo and Nguyen toured the kitchen and food storage areas. LPAs observed there to be a perishable food supply adequate for at least two days and a non-perishable food supply of at least seven days. LPAs observed facility kitchen staff preparing meals. LPAs toured the laundry room and observed staff providing laundry service. LPAs then toured the Assisted Living Dinning Area and food preparations for the residents. LPAs interviewed residents R1-R7. Seven out of seven interviewed residents stated that the facility was continuing to provide food service, hygienic supplies, assistance with medications when needed, and available staff. LPAs toured six resident bathrooms and one hallway bathroom and found the water temperature to be between 108 F to 109 F. Each bathroom had working lights, paper towels, and available soap. LPAs observed thermostats to be set to 70 F. LPAs observed the medication room and found it to have a first aid kit, Centrally Stored Medication Log, Medical Administration Record, and stored medications. LPAs observed 22 staff during visit.

During visit, LPAs obtained copies of the following facility documents: LIC500 Personnel Report, Resident Roster, and actual staff work schedule for the month of March 2021.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Assisted Living Director Sharon Fay and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021
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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