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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 10/26/2021
Date Signed: 10/26/2021 01:04:22 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: 59DATE:
10/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tracey LundyTIME COMPLETED:
01:15 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 dining room and laundry room. Laundry room in operation and 1 Laundry room attendant was present. Facility interior room temperature was 71.4 degrees Fahrenheit (F).

At 12:00pm 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, Dietary Manager, 1 host, 3 staff and 3 servers. Staff were serving lunch to include assorted fresh fruit, Chipolte chicken sandwich, fried chicken and mashed potatoes. There were 8 residents dining at individual tables. Other residents were picking up food orders to go.

At 12:15pm LPA observed Administrator, 2 Certified Nursing Assistants (CNAs), and Health Navigator, Maintenance Director, receptionist and staff screening visitors. Facility is providing direct care services for residents, housekeeping, food service, and property maintenance. Staffing levels stable. Facility hired two new staff members to start work in November 2021.

Activities today include ice cream social and Halloween Pumpkin Decorating Contest.

LPA obtained LIC500 dated 10/23/2021 and copy of staff schedules for October 2021 and Front Desk Schedule for October and November 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: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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