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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:06:25 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:
02/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 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, kitchen, dining room, cafe, Fireside Lounge, Assisted Living (AL) area, bathrooms and common areas. Communal dining room is open. All Visitors entering the building are screened. Menu offerings for lunch include Italian Pasta & Steak Salad Plate, Chicken Marsala, and Banana Pudding. Premier dinner entrees today are Rack of Lamb and Filet Mignon.

At 10:45am LPA observed Chef manager, 4 kitchen staff, 2 servers and host in the dining area. Administrator and 3 Certified Nurse Assistants (CNAs) and 1 Housekeeper were observed in AL. Laundry room operational and 2 Laundry room attendants present.

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 2/7/2022 and 2/8/2022, and Menu for the Week of 2/6-2/12/2022. Today's activities to include Low Impact Aerobics, Dining Room Committee Meeting, local shopping, and musical entertainment.

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: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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