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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:14:24 PM


Document Has Been Signed on 07/28/2022 03:14 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: 96DATE:
07/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Sharon FayTIME COMPLETED:
03:30 PM
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On 7/28/22, Licensing Program Analysts (LPAs) M. Medina and V. Gorban conducted an unannounced Case Management Health Check visit. LPAs were screened from window for COVID-19 symptoms and completed questionaires. LPAs met by Sharon Fay, RN Director of Resident Health Services/Administrator and stated purpose of visit.

LPAs completed tour of facility with Sharon Fay. Staff observed to be wearing facing masks through out facility. All common areas which include lobby, dining room, cafe, kitchen, and resident rooms in Assisted Living. Communal dining room has resumed. Residents who chose to remain in their room have meals delivered to their room. Visitation guidelines are still in effect. Fire extinguishers present with a service date of 4/18/22.

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, and memo to Forest Hill Family, Residents and Staff dated 7/25/22.

No deficiencies observed during today's visit.

Exit interview conducted. A copy of report left with Administrator for facility files.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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