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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:36:22 PM


Document Has Been Signed on 05/11/2022 03:36 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, 1314 E SHAW AVE
FRESNO, CA 93710



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: 62DATE:
05/11/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Sharon FayTIME COMPLETED:
03:49 PM
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On 5/11/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management - Health Checks visit. LPA met by Sharon Fay, RN Director of Resident Health Services and stated purpose of visit. All staff and visitors arriving are screened from window and complete a COVID questionnaire prior to being allowed entrance.

LPA toured the facility with Sharon Fay which included all common areas, dining room, in part to include lobby, dining room, cafe, kitchen, and resident rooms in Assisted Living. Communal dining room is currently closed. Meals are being delivered to resident rooms. Residents are provided masks to be worn in all common areas. Visitation guidelines are still in effect. Fire extinguishers present with a service date of 4/18/22, water temperature measured at 109 degrees F.

Adequate staffing is available. The facility has an adequate supply of Personal Protective Equipment (PPE) on site which incudes: masks (surgical and N95), gowns, face shields, gloves, bio hazard, and disinfectant wipes.

LPA received copies of LIC 9020, current staff schedule, dining menus and memo to Forest Hill Family and Staff dated 5/9/22.

No deficiencies observed during today's visit.

Report reviewed with Sharon Fay and a copy provided for facility records..
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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