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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 12/22/2021
Date Signed: 12/22/2021 10:23:17 AM

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: 64DATE:
12/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sarah EhretTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Health Check visit and met with Sarah Ehret. The visit was conducted virtually over Zoom.

During visit, LPA Marrufo observed the dinning area, kitchen, and food storage areas. LPA Marrufo observed staff preparing meals in the kitchen. The facility menu was observed. LPA Marrufo observed the pantry room, freezer room, and meat storage room and observed a food supply of 7 days and an emergency food supply of 7 days. LPA Marrufo observed a room filled with paper supplies. LPA Marrufo observed a weekly events calendar and a COVID-19 related poster. LPA Marrufo observed a PPE supply room and observed a 90-Day supply of masks, gloves, paper towels, cleaning supplies, face shields, goggles, and gowns.

LPA Marrufo observed residents in the activities areas, hallways, and elevators. The medication station and medication room were observed and staff were observed to be working there. Facility lights were observed to be on during the visit and the elevators were observed to be functioning. LPA Marrufo observed 15 staff during the visit. The census includes 50 Independent Living residents and 14 Assisted Living residents.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Sarah Ehret and a copy of the report will be sent to her for her to sign and return to the Department.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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