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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 02/02/2022
Date Signed: 02/03/2022 07:18:00 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: 64DATE:
02/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sarah EhretTIME COMPLETED:
11:30 AM
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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 explained the purpose of the visit.

LPA toured the facility in part to include lobby, dining room, cafe, fireside lounge, bathrooms and common areas. Communal dining room is closed. Meals are delivered to resident rooms or prepared for to go. Activities are limited to small groups. Residents are wearing masks in common areas. Visitation is limited to outdoor visits or window visits. There are visit exceptions. All persons entering the building are screened.

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

LPA obtained Register of Facility Residents, Forest Hill Residents, Family & Staff Memos dated 1/28/2022 and 1/31/2022, February Activity Calendar, and Menu for the Week of 1/30-2/5/2022. Today's activities to include Low Impact Aerobics and Tai Chi. Menu offerings for lunch include Ginger Sesame Salad with Chicken, Tuna Melt on Rye, Teriyaki Chicken and Sweet Honey Cornbread.

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

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

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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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