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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 01/12/2022
Date Signed: 01/14/2022 08:12:15 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:
01/12/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Tracey LundyTIME COMPLETED:
01:25 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) Marybeth Donovan conduced an unannounced visit to conduct a Case Management - Health Checks visit and met with Tacey Lundy Office Manager. LPA explained the purpose of the visit.

LPA toured the facility inside and out to include Assisted Living (AL), bathrooms, kitchen, dining room, lounge, and offices. Facility interior room temperature was 74 degrees Fahrenheit (F). AL common area bathroom hot water temperature measured at 114.8 degrees (F).

At 12:40pm in the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Fresh fruit of bananas and pineapples were observed. Kitchen staff consisted of Chef Manager, Dining Room Manager and 8 staff. Staff were in the process of preparing to go meals and room service meals. Lunch menu consisted of Minestrone Soup, Green Salad, Greek Burger, Creole vegetables with rice, Mac & Cheese, and deserts of pudding and blueberry muffins.

At 12:50pm in AL, LPA observed Administrator and 2 Certified Nursing Assistants (CNAs). Facility is providing services for residents to include direct care and property maintenance. Staffing levels stable. Activities today included aerobic exercise class, Tai Chi class and Resident Activities and Program Committee Meeting. Social distancing and masking protocols being observed.

LPA obtained Forest Hill Memo to Residents, Family and Staff dated 1/11/2022 regarding COVID-19 Updates and Changes in Dining Room and Town Hall Meeting Notes 1/7/2022.

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: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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