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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 08:28:20 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: 65DATE:
01/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Sarah Ehret and Tracey LundyTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Sarah Ehret Executive Director and Tracey Lundy Office Manager

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Emergency EVAC Chair observed in the 5th Floor Stairwell. LPA observed a minimum 30 day supply of PPEs, cleaning products, disinfectants and other emergency preparedness supplies. These supplies are inventoried and restocked regularly. Staff providing direct care are N95 FIT Tested.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Bathrooms observed to be supplied with hygiene products and hand washing signs posted. Hand sanitizer stations available throughout the facility. Postings included Visitor Policy, Notice of COVID Risks, COVID Precautions and COVID Visitors Questions.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, N95 Fit Testing and PPE usage.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Tracey Lundy Office Manager and a copy of this report 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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