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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 08/13/2021
Date Signed: 08/14/2021 08:16:16 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: 59DATE:
08/13/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Tracey LundyTIME COMPLETED:
04:10 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 Tracey Lundy Business Manager. LPA explained the purpose of the visit. Monthly All Staff meeting being conducted in the dinning room. New COVID 19 polices and procedures being reviewed with staff.

LPA 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. Facility interior room temperature was 76 degrees Fahrenheit (F). Hall bathroom in AL water temperature measured at 113 degrees Fahrenheit (F). Bathrooms contained supply of hygiene items, soap and paper towels. Hand washing signs posted.

In the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. LPA observed fresh fruit of strawberries, raspberries, blueberries, watermelons, bananas, and pineapple. Two kitchen staff were present prepping for dinner and stocking delivery items. Dinner entree items consist of fresh salmon and braised pork.

At 3:15pm LPA observed 2 CNAs in AL.

Resident services being provided include direct care needs, food service, housekeeping, medication management and activities. Staffing levels stable. LPA obtained updated resident roster, Menu for week of 8/15/2021, All Staff Meeting Agenda and COVID Information and Updates for 8/13/2021.

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: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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