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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 06/18/2021
Date Signed: 06/21/2021 07:39:08 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:VICKIE ZUFELTFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 51DATE:
06/18/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sarah EhretTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management – Health Check visit and met with Sarah Ehret Executive Director. LPA explained the purposed of the visit. LPA toured the facility to include lobby, dining room, kitchen, pantry, walk in cooler, cold storage, basement, laundry room, Bistro, Fireside Lounge, and Assisting Living (AL) and Independent Living (IL) area. Facility interior room temperature was 77 degrees Fahrenheit (F). Water temperature in AL Bathroom measured at 113 degrees F. Bathroom contained supply of hygiene items, soap and paper towels.

LPA observed a minimum of 2 day perishable food supply and 7 day non perishable food supply. LPA observed fresh fruit of bananas, pineapple and watermelon in the kitchen. Lunch prep was in process. Staff preparing fresh jumbo shrimp for pineapple salad. Other menu items included Fennel Salad, Cubano sandwich, Brussels sprouts and rice. Kitchen equipment included a new dishwater, water filtration system and coffee dispensers. Water station available in the lobby for residents.

In AL LPA observed 3 staff. One staff member was out of the community with resident. Also, LPA observed 3 Administrative staff, 1 receptionist, 1 LVN (Screening Visitors) and 2 laundry attendants. Laundry room was in operation. Maintenance Director advised today he has 5 housekeepers working in the community. Interim Administrator Certificate current. Based on review of staff schedule and observations, staffing was sufficient at the facility.LPA interviewed 4 residents and care needs are being met. The facility is providing services to include activities of daily living, food service, housekeeping, medication management and activities. LPA obtained copies of Personnel Report LIC500, Register of Facility Residents LIC9020, and Menu for the week of June 20th 2021.

No deficiencies cited during this visit per the California Code of Regulations Title 22.
Report review 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: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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