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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 09/26/2022
Date Signed: 09/26/2022 10:20:39 AM


Document Has Been Signed on 09/26/2022 10:20 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: 62DATE:
09/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Sharon FayTIME COMPLETED:
10:22 AM
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On 9/26/22, 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 questionnaires. LPA stated purpose of visit and allowed entrance. LPA met with Sharon Fay, Administrator.

LPA observed staff to be wearing face masks through out facility. Visitation guidelines are still in effect. Currently, two residents on Hospice.

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 staffing schedule, LIC 9020 (Register of Facility Clients/Residents), and current staff schedule, and memos to Forest Hill Family, Residents and Staff dated 9/19/22. LIC 500 Personnel Report received during 9/12/22 case management visit and there have been no changes.

No deficiencies observed during today's visit.

Exit interview conducted. A copy of report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
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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