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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 04/16/2022
Date Signed: 04/18/2022 02:57:36 PM


Document Has Been Signed on 04/18/2022 02:57 PM - It Cannot Be Edited

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: 60DATE:
04/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Health Service Administrator Tamara SolariTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility April 16, 2022 at 02:15 p.m. for a Case Management - Health Checks visit. LPA met with Health Service Administrator Tamara Solari 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 by front desk staff before allowed entrance to the building.

LPA observed sufficient perishable and Non-perishable food supply. Menu offerings for dinner include Italian Wedding soup, stuffed Portobello mushrooms, pork loin, mixed vegetables, and baked cookies..

LPA observed 3 kitchen staff, 6 servers and host in the dining area. LPA observed 4 Certified Nurse Assistants (CNA's) and 1 Licensed Vocational Nurse (LVN) in assisted living. LPA observed activities staff painting with several residents. Care services are being provided. Staffing is stable. LPA spoke with several facility staff and all stated they are being paid correctly and accurately.

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

Report reviewed with Health Service Administrator Tamara Solari and a copy provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2022
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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