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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 06/01/2021
Date Signed: 06/21/2021 07:39:29 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:VICKIE ZUFELTFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 40DATE:
06/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sarah Ehret and Sharon FayTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management – Health and Safety visit and met with Sarah Ehret Executive Director and Sharon Fay Interim Administrator. LPA explained the purposed of the visit. LPA toured the facility inside and out to include lobby, dining room, kitchen, pantry, walk in cooler, cold storage, Bistro, Fireside Lounge, and Assisting Living (AL) and Independent Living (IL) area. Facility interior room temperature was 71 degrees Fahrenheit (F). Water temperature in AL Bathrooms measured at 109.6 and 109.9 degrees F. Bathroom contained supply of hygiene items, soap and paper towels.

LPA observed a minimum of 2 day perishable food supply and 7 day non perishable food supply. LPA observed fresh fruit of bananas, pineapple and watermelon in the kitchen. Dinner prep was in process. Staff preparing roasted artichokes, Beef Burgundy, roasted turkey, butter noddles and roasted potatoes.

In AL LPA observed Administrator, 1 nurse, 2 Certified Nurse Assistants and 1 staff in training. Based on review of staff schedule and observations, staffing was sufficient at the facility.

LPA interviewed residents and care needs are being met. The facility is providing services to include activities of daily living, food service, housekeeping, medication management and activities.

LPA obtained copies of Personnel Report LIC500, Register of Facility Residents LIC9020, and Menu for the week of May 30 through June 5. 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 email for signature due to technical issues.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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