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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 01/07/2022
Date Signed: 01/08/2022 08:29:05 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: DATE:
01/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Sarah Ehret Executive Director and Tracey Lundy Office ManagerTIME COMPLETED:
03:00 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 Sarah Ehret Executive Director and Tracey Lundy Office Manager. LPA explained the purpose of the visit.

LPA toured the facility with Joey Garcia Director of Maintenance to include Independent Living (IL), Assisted Living (AL), supply room, bathrooms, kitchen, pantry, dining room, lounge, laundry room and offices. Facility interior room temperature was 72 degrees Fahrenheit (F). AL bathrooms hot water temperature measured at 114.3 and 112.5 degrees (F).

At 12:30pm in the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Fresh fruit of bananas, melons and pineapples were observed. Kitchen staff consisted of Dining Room Manager and 6 staff. Staff were finishing lunch service. Lunch menu consisted of Navy Bean Soup, Prime Rib, Poached Salmon and fresh fruit.

At 12:45pm in AL, LPA observed 3 Certified Nursing Assistants (CNAs), 1 housekeeper. Laundry room was operational and 2 laundry room attendants present. Facility is providing direct care services for residents, housekeeping, food service, and property maintenance. Staffing levels stable. Activities today included aerobic exercise class, Tai Chi class and Happy Hour.

LPA obtained Notification to Residents for Semi-Annual Meeting on 1/20/2022, Forest Hill Memo dated 1/7/2022 regarding COVID-19 Testing and Visitation Guidelines and January Activity Calendar.

No deficiencies cited during this visit per the California Code of Regulations Title 22.

Report reviewed 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: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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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