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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 06/23/2021
Date Signed: 06/28/2021 06:43:59 AM

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: 52DATE:
06/23/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Sarah EhretTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management - Health Check visit and met with Sarah Ehret Executive Director (ED) Sharon Fay Administrator and Tracey Lundy Business Office Manager. LPA explained the purpose of the visit.

LPA toured the facility to include lobby, dining room, kitchen, pantry, walk in coolers, cold storage, basement, boiler room, laundry room, Bistro, Fireside Lounge, and Assisting Living (AL) and Independent Living (IL) area. Facility interior room temperature was 74 degrees Fahrenheit (F). Water temperature in AL Bathroom measured at 113 degrees F. Bathroom contained supply of hygiene items, soap and paper towels.

In the kitchen LPA observed a minimum of 2 day perishable food supply and 7 day non perishable food supply. LPA observed fresh fruit of bananas, pineapple and watermelon in the kitchen. Lunch prep was in process. Staff preparing fresh chicken and shrimp gumbo, sandwiches, fresh fruit bowls and chocolate cake with strawberries.

At 2:00pm LPA observed AL residents participating in music sing along activity in the 2nd floor dining room. In AL LPA observed Administrator, 3 staff and 1 housekeeper present.

Also, LPA observed 3 administrative staff, 1 receptionist, 1 chef, 8 kitchen staff, 1 host, 2 dining room servers, 1 laundry room attendant and 3 maintenance staff on site. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

At 2:30pm LPA attended Weekly Chat with residents. ED discussed facility operations and addressed questions and concerns. There were 12 resident participants in the Fireside Lounge and additional participants following the meeting virtually.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FOREST HILL
FACILITY NUMBER: 270700245
VISIT DATE: 06/23/2021
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LPA interviewed Executive Director, 1 staff and 10 residents. The facility is providing services to include activities of daily living, food service, housekeeping, medication management and activities.

LPA review 13 resident files to include Admission Agreements, Medical Assessments, Appraisal Needs and Services Plans, Emergency Contact Information and Personal Rights forms.

LPA obtained copies of Personnel Report LIC500, Update to Register of Facility Residents LIC9020, Staff Schedule for June 2021, Town Hall Meeting Notes for 6/4/201, Budget Presentation Meeting Notes 5/25/2021, Disclosure Acknowledgement form and Menu for the week of June 20-26th 2021.

No deficiencies cited during this visit per the California Code of Regulations Title 22.

Report review with Sarah Ehret Executive Director and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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