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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 08/17/2022
Date Signed: 08/18/2022 09:30:52 AM


Document Has Been Signed on 08/18/2022 09:30 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, 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: 60DATE:
08/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:23 PM
MET WITH:Sharon FayTIME COMPLETED:
05:34 PM
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On 8/17/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management Health Check visit. LPA were screened from window for COVID-19 symptoms and completed questionaires. LPA greeted by Tracey Lundy, Office Manager and stated purpose of visit. Sarah Ehret, Executive and Sharon Fay, RN Director of Resident Health Services/Administrator.

Staff observed to be wearing facing masks through out facility. Visitation guidelines are still in effect. Currently, one resident on Hospice. 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 8/05/22 & 8/15/22.

No deficiencies observed during today's visit.

Exit interview conducted. Due to LPA printer issues, this report will be e-mailed.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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