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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 11/18/2021
Date Signed: 11/19/2021 06:03:03 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: 64DATE:
11/18/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Tracey LundyTIME 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 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. Facility interior room temperature was 74 degrees Fahrenheit (F). AL common bathroom hot water temperature measured at 113 degrees (F).

At 2:30am 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 were observed. Kitchen staff consisted of Chef Manager, 4 staff , 1 host and 2 servers. Staff were prepping dinner to include Tri-Tip, Rastatouille Stuffed Portobello Mushrooms, pineapple coleslaw and cupcakes.

At 2:45pm in AL, LPA observed Administrator, 2 Certified Nursing Assistants (CNAs), 1 Health Navigator, 1 Housekeeper and 1 Laundry Attendant. Facility is providing direct care services for residents, housekeeping, food service, and property maintenance. The facility now has optional on site medical care provider available 24/7. Staffing levels stable.

Activities today included Circuit raining, Catholic Services, Nurse Chat and Resident Association Meeting.

LPA obtained Forest Hill Residents, Family & Staff Weekly Memos dated 11/122021 and 11/15/2021, Medical Director Announcement dated 11/9/2021 and updated roster, and Weekly Events Calendar.

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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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