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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 08/02/2021
Date Signed: 08/02/2021 03:04:22 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:
08/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Tracey LundyTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Marybeth Donovan and Christine Dolores conduced an unannounced visit to conduct a Case Management - Health Checks visit and met with Tracey Lundy Business Manager. LPAs explained the purpose of the visit.

LPAs toured the facility inside and out to include in part Assisted Living (AL), lounge, cafe, bathrooms, kitchen, dining room, pantry, walk in cooler and freezer, emergency food supply storage, break room. Facility interior room temperature was 77 degrees Fahrenheit (F). Bathrooms contained supply of hygiene items, soap and paper towels. Hand washing signs posted.

In the kitchen LPAs observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. LPA observed fresh fruit of watermelons, bananas, and pineapple. Kitchen staff were cleaning the kitchen for dinner prep.

At 2:00pm in AL LPAs observed 2 CNAs .Also, LPAs observed 2 administrative staff, 1 receptionist, Dietary Manager, 5 kitchen staff, 1 host, 1 laundry room attendant and 1 van driver. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

Bob Phillips Jazz Band performing for the residents in the Fireside Lounge.

Resident services being provided include direct care needs, food service, housekeeping, medication management and activities. LPAs obtained Menu for week of 8/1/2021, August Activities Calendar and staff schedule for August 2021.

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

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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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