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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 11/10/2021
Date Signed: 11/10/2021 10:22:04 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: 60DATE:
11/10/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Tracey LundyTIME COMPLETED:
10:30 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 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, and dining room. Facility interior room temperature was 73 degrees Fahrenheit (F). AL common bathroom hot water temperature measured at 111.2 degrees (F).

At 9:30am in the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Fresh fruit of bananas, pineapple, melons and assorted berries were observed. Kitchen staff consisted of Chef Manager, 7 staff , 2 hosts and 1 server. Staff were prepping lunch to include Tofu Stir-Fry and Turkey & Cranberry sandwiches.

At 10:00am in AL, LPA observed Administrator, 4 Certified Nursing Assistants (CNAs), Health Navigator and 1 housekeeper. Facility is providing direct care services for residents, housekeeping, food service, and property maintenance. Staffing levels stable.

Activities today include Shopping outing and aerobic exercises programs.

LPA obtained Forest Hill Residents, Family & Staff Weekly Memo dated 11/8/2021 and Town Hall Meeting Notes dated 11/5/2021.

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: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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