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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 05/03/2021
Date Signed: 05/05/2021 10:46:11 AM

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: 44DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sarah EhretTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management – Health and Safety visit and met with Sarah Ehret Executive Director and Tracey Lundy Office Manager. LPA explained the purposed of the visit. LPA toured the facility to include kitchen, pantry, cold storage, freezer and dining room, basement, laundry room, supply storage area, lobby, Fireside Lounge, Independent Living (IL) and Assisting Living (AL) areas. Laundry room was operational. Laundry Attendant completed service for the day. Facility interior room temperature was 75 degrees Fahrenheit (F). Water temperature in AL Bathroom measured at 116.6 degrees F. Bathroom contained supply of hygiene items, soap and paper towels.

LPA observed a minimum of 2 day perishable food supply and 7 day non perishable food supply. LPA observed fresh fruit of strawberries, blueberries, raspberries, pineapple, melon, and bananas. The Chef and 4 staff were working. Dinner prep in process. Dinner menu in part included braised lamb, turkey, roaster beets and parslied potatoes.

Centrally Stored Medications are kept in a locked medication cart in the AL area. Medication Administration Record is maintained on computer software program and manually on a written log for back up purposes. First Aid Kit was complete. LPA observed Administrator, 3 staff and 1 housekeeper working in AL area.

LPA observed Musician playing piano music for residents in the Fireside Lounge.

LPA interviewed 6 residents who stated that their care needs are being met . The facility is providing services as needed or requested to include activities of daily living, food service, housekeeping, medication management assistance and group activities.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FOREST HILL
FACILITY NUMBER: 270700245
VISIT DATE: 05/03/2021
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LPA obtained copies of Personnel Report LIC500, Register of Facility Residents LIC9020, Staff Schedule for May 2021, and Menu for Week of 5-2-2021.

Based on review of staff schedule and observations, staffing was sufficient at the facility.

No deficiencies cited during this visit per the California Code of Regulations Title 22. Report review with Sarah Ehret and a copy emailed for signature due to technical issues with computer
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
LIC809 (FAS) - (06/04)
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