<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:15:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 65DATE:
12/03/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tracey LundyTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Health Check visit and met with Tracey Lundy, Office Manager

During visit, LPA Marrufo toured the dinning room, kitchen, and food storage areas. LPA Marrufo observed 11 kitchen staff, a 7 day supply of food, and a 7 day emergency food and water supply. LPA Marrufo observed 11 more staff during the visit.

LPA Marrufo interviewed 7 residents in Assisted Living and 3 residents in Independent Living. All interviewed residents stated that the facility provides them with enough meals, assistance with medications, assistance with maintaining a clean living unit, and warm water temperatures in the bathrooms. LPA Marrufo measured the water temperatures in the resident bathrooms, which measured between 106F-115F.

LPA Marrufo observed the town hall meeting being conducted between staff and residents. LPA Marrufo observed facility staff discussing the food services being provided for residents during the town hall meeting. LPA Marrufo obtained a copy of the current staff schedule.

The census for the facility includes 15 for Assisted Living and 50 for Independent Living.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Tracey Lundy and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1