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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:38:08 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: 60DATE:
11/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sarah Ehret TIME COMPLETED:
03:45 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 Sarah Ehret Executive Director and 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 and dining room. Interior room temperature was 72 degrees Fahrenheit (F). Bathroom temperature in the AL hall bathroom measured at 109 degrees (F).

At 2:55pm LPA observed 3 Certified Nursing Assistants (CNAs), and 2 Nurses in AL. Also, LPA observed Maintenance Director, receptionist, host and van driver. Facility is providing direct care services for residents, food services and housekeeping. Staffing levels stable.

LPA obtained updated resident roster, November Activity Calendar, Weekly Memo dated 11/1/2021, and Forest Hill News Letter dated November 2021. COVID Booster Clinic scheduled for 11/4/2021.

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

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

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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