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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:18:59 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:
08/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sarah Ehret and Tracey LundyTIME COMPLETED:
03:30 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 to include in part Assisted Living (AL), lounge, cafe, bathrooms, kitchen, dining room, pantry, walk in cooler, freezer and laundry room. Laundry room in operation. 1 housekeeper present. 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 watermelons and pineapple. Chef Manager, new Chef and 5 kitchen staff were present. Kitchen staff prepping for dinner service to include fried chicken and eggplant Parmesan.

At 2:30pm in AL LPA observed 3 Certified Nurse Assistants (CNAs) and 1 housekeeper. Also, 2 dining room servers were delivering fruit smoothies to residents. Other staff preparing for August Birthday Celebration in the Fireside Lounge. On Saturday 8/21/2021 they are celebrating Senior Citizen Day outdoors on the patio featuring live entertainment.

Resident services being provided include direct care needs, food service, housekeeping, medication management and activities. Staffing levels stable. LPA obtained updated resident roster.

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

Report review with Sarah Ehret Executive Director and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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