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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 07/20/2021
Date Signed: 07/21/2021 03:46:10 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:SHARON FAYFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 58DATE:
07/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Sarah Ehret, Sharon Fay and Tracey LundyTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management - Health Checks visit and met with Sarah Ehret, Sharon Fay Administrator and Tracey Lundy Business Manager. LPA explained the purpose of the visit.

LPA toured the facility inside and out. Facility interior room temperature was 72 degrees Fahrenheit (F). Water temperature in AL hall bathroom measured 105.8 degrees F. Bathrooms contained supply of hygiene items, soap and paper towels. In the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. LPA observed fresh fruit of melons, bananas, pineapple and strawberries. Lunch service finished. Staff were breaking down lunch service to begin dinner prep. Dinner entrees to include roasted Pork Loin and Sole Francese. Alternatives menu items available.

At 1:30pm in AL LPA observed Administrator, 2 Certified Nurse Assistants (CNAs) and 1 housekeeper present. Singing music activity in the dining room.

Also, LPA observed 3 administrative staff, 1 receptionist, 1 staff (screening visitors), Chef Manager, 6 kitchen staff, 2 servers, Director of Maintenance, 1 laundry room attendant. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

Resident services being provided to include direct care needs, food service, housekeeping, medication management and activities. LPA obtained Menu for July 18-31, 2021, AL July Activities Calendar, kitchen staff schedule for July 18-31, 2021 and Resident Weekly Memos dated July 12, 2021 and July 19, 2021.

No deficiencies cited during this visit per the California Code of Regulations Title 22.
Report reviewed with Tracey Lundy Business Manager and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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