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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:34:49 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:
09/08/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sarah EhretTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPAs) Marybeth Donovan and Christine Dolores 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.

At 2:30pm LPAs attended Weekly Chat with Residents. 13 residents and 1 staff member attended. Other residents attended via Zoom link. Sarah Ehret conducted the meeting. The topics included vaccination clinic, update to resident handbook and phone directory, Resident Satisfaction Survey Meeting, elevator maintenance, kitchen remodel and COVID 19 updates to include screening and visitation policies.

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

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

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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