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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 01/20/2022
Date Signed: 01/20/2022 06:04:09 PM

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:
01/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sarah Ehret and Tracey LundyTIME COMPLETED:
04:30 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 in part. LPA reviewed facility COVID Mitigation Plan with Sarah Ehret Executive Director. The facility communal dinning room is closed. Meals are being delivered along with snacks during the day and evening. Paper products and disposable utensils are being utilized. Medications administered in residents rooms. Activities conducted with reduced participants, social distancing and masks. Walking outings with small groups encouraged. Facility is deep cleaned and disinfecting twice a day. High touched surfaces are cleaned every shift and as needed.

Care services are being provided. Staffing is stable. The facility has minium 30 day supply of PPEs on site.

LPA obtained Forest Hill Residents, Family & Staff Memos dated 1/17/2022, 1/18/2022, and Semi Annual Meeting Agenda Notes dated 1/20/2022.

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

Report reviewed with Sarah Ehret Executive Director and a copy emailed due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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