270700245-5-13-2021-26-AS-KHOS-C38PBW-20210521111101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 270700245
Report Date: 05/06/2021
Date Signed: 05/13/2021 08:58:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20201014161802

FACILITY NAME:	FOREST HILL		FACILITY NUMBER:	270700245
ADMINISTRATOR:	ROSETTA W. CHAN		FACILITY TYPE:	741
ADDRESS:	551 GIBSON AVENUE		TELEPHONE:	(831) 657-5200
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	150	CENSUS: 44	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sarah Ehret		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff installed a listening device in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit due to COVID -19 Pandemic restrictions to deliver the complaint investigation finding. LPA met with Sarah Ehret, Executive Director.

On 10/14/2020 and on 3/4/2021 tours of the facility were conducted virtually and on site. Between 10/19/2020 and 5/2/2021 interviews were conducted with 4 staff and 6 residents. Records reviewed included Plan of Operation, Residency Agreements, Facility Sketch, Nest Cam Settings and Nest Aware Application information, and facility photographs.

2 of 4 staff stated that 2 video cameras were installed behind the front lobby desk in May 2019 for the purpose of monitoring the front desk coverage. The cameras’ view was of the the front desk area only. Monitoring was discontinued in August of 2019. These cameras did not record any audio/sound. The other two staff were unaware of any cameras installed behind the front desk or if any there was any sound recording device

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201014161802

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: FOREST HILL	FACILITY NUMBER: 270700245
	VISIT DATE: 05/06/2021

NARRATIVE

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6 of 6 residents interviewed had no knowledge of any cameras installed behind the front lobby desk or if any audio device was recording sounds or any communications.

During tours LPA observed one video camera had been removed from the front desk and the other had a monitor placed in front of it to block visual. Settings information reviewed indicated Microphone Off. Residency Agreement notes the facility uses video surveillance in some of the common areas for security purposes.

The Department has investigated the above allegation. Based on information from interviews conducted, records reviewed, and observations although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Report reviewed with Sarah Ehret Executive Director and a copy of this report emailed for signature.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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