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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 09/23/2021
Date Signed: 09/24/2021 06:49:58 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:
09/23/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarah EhretTIME COMPLETED:
11:20 AM
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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 in part to include Assisted Living (AL), lounge, bathrooms, kitchen, dining room, freezer and walk in cooler, emergency supply storage and laundry room. Facility interior room temperature was 75 degrees Fahrenheit (F). Bathrooms contained supply of hygiene items, soap and paper towels. Hand washing signs posted and hand sanitizer stations available throughout the facility.

At 10:15am in the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Kitchen staff consisted of Chef Manager, 4 staff, 3 servers and 1 host. Staff were prepping for room meal service. Kitchen staff using disposal paper products as part of their meal service COVID 19 Prevention and Mitigation plan. Communal dining and activities discontinued at this time. Activity Packets are being delivered to residents rooms.

At 10:30am LPA observed 2 Certified Nursing Assistants (CNAs) and Health Navigator (LVN) in AL.

Facility is providing direct care need services for residents, housekeeping, food service, and maintenance. Staffing levels stable. LPA obtained copy of current resident roster, Facility Memos to Residents & Family & Staff dated 9/22/2021, Memorandum dated 9/22/2021, and Memo dated to Residents and Staff dated 9/20/2021.

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: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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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