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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:54:54 AM


Document Has Been Signed on 10/19/2022 11:54 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:
10/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sarah Ehert, Executive Director
Tamara Solari, Interim Executive Director		TIME COMPLETED:
12:04 PM
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On 10/19/2022, Licensing Program Analysts (LPAs) M. Medina and S. Hurt conducted a Case Management visit. COVID-19 screening protocols continued to be in place, LPAs screened upon entrance. All staff observed to be wearing face mask throughout facility.

LPAs toured kitchen with Robert Kershner, Dining Director. LPAs observed a 2-day supply of perishable food and a 7-day supply of non-perishable food available for residents.

Assisted Living area toured with Sharon Fay, Administrator. Residents observed to be participating in activity and others relaxing in their bedrooms. Currently there are 2 residents receiving hospice services.

LPA observed copies of updated LIC 500, staff schedule, LIC 9020, weekly menu, and Memo to Forest Hill families, residents and staff dated 10/10 & 10/17/22.

No deficiencies observed during visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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