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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 07/28/2021
Date Signed: 07/30/2021 08:21:10 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:SHARON FAYFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 58DATE:
07/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sarah Ehret and Tracey LindyTIME COMPLETED:
04:30 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 Executive Director and Tracey Lundy Business Manager. LPA explained the purpose of the visit.

LPA toured the facility inside and out. Facility interior room temperature was 75 degrees Fahrenheit (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 watermelons, bananas, and pineapple. Staff were starting prep for dinner. Dinner entrees to include beef short ribs, fried catfish and chicken Florentine. Alternatives menu items available.

At 2:15pm in AL LPA observed Administrator, 1- LVN, 2 Certified Nurse Assistants (CNAs) and 1 housekeeper present. Singing music activity in the dining room.

At 2:30pm LPA attended Bi-Weekly Chat with residents conducted by Sarah Ehret Executive Director in the Fireside Lounge. 8 residents attended in person and residents participated via Zoom platform. Also present were 2 staff. Topics discussed included facility budgets, elevator and equipment maintenance, technology upgrades, facility logo and COVID 19 strategies.

Also, LPA observed 3 administrative staff, 1 receptionist (screening visitors), Chef Manager, 4 kitchen staff, 2 servers and Director of Maintenance. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

Report continued on Page 2.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/28/2021
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Resident services being provided to include direct care needs, food service, housekeeping, medication management and activities. Today’s activities included Pool Players Club and Photographers Scenic Drive.

No deficiencies cited during this visit per the California Code of Regulations Title 22.

Report reviewed with Sarah Ehret Executive Director and a copy emailed for signature due to technical issues.


Page 2
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2