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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 04/23/2022
Date Signed: 04/23/2022 11:02:59 AM


Document Has Been Signed on 04/23/2022 11:02 AM - 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: 110DATE:
04/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Mary Lou KelpeTIME COMPLETED:
11:11 AM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check.

LPA evaluated the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility with staff including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room, smoking area and backyard area. The facility has a carbon monoxide detectors in the laundry area on the assisted living. LPA observed the facility to be free of odor and in good repair. LPA observed that rooms inspected are equipped with the required furniture and there is sufficient lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water was tested and measured at 112.5*F on the assisted living side.
Health and Safety check today included the overall safety of the facility including food supply, physical plant and staffing.

No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Advisories given

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2022
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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