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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:58:52 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:
10/12/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Tracey LundyTIME COMPLETED:
03:00 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 Office Manager. LPA explained the purpose of the visit.

LPA toured the facility in part to include Assisted Living (AL), lounge, bathrooms, kitchen, pantry, freezer, walk in cooler, supply storage, dining room, and laundry room. Facility interior room temperature was 72 degrees Fahrenheit (F). AL common bathroom hot water temperature measured at 114 degrees (F). Bathrooms contained supply of hygiene items, soap and paper towels. Hand washing signs posted and hand sanitizer stations available throughout the facility.

At 2:10pm in the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Fresh fruit of bananas, pineapple and assortment of melons were observed. Kitchen staff consisted of Chef Manager, 4 staff, 3 servers and 1 host. Staff were beginning dinner prep to include fresh made beef stew and angel food cake.

At 2:30pm LPA observed Administrator, 3 Certified Nursing Assistants (CNAs), Health Navigator and 1 housekeeper in AL. Facility is providing direct care services for residents, housekeeping, food service, and property maintenance. Staffing levels stable. Vaccine Booster Clinic was conducted as scheduled on 10/11/2021. Flu Clinic is scheduled for 10/19/2021. Today's activities included an outing to The Farm for pumpkins and other fall festivities.

LPA obtained Forest Hill Residents, Family & Staff Weekly Memo dated 10/11/2021.

No deficiencies cited during this visit per the California Code of Regulations Title 22.
Report review with Tracey Lundy Office Manager and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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