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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:59:25 AM


Document Has Been Signed on 10/26/2022 11:59 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: 61DATE:
10/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Sarah Ehert, Executive Director
Sharon Fay, RN/Administrator		TIME COMPLETED:
12:17 PM
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Licensing Program Analysts (LPA) M. Medina conducted an unannounced Case Management Health Check visit. All COVID-19 precautions remain in place, all staff observed to be wearing masks throughout facility. LPA met Sarah Ehert and Sharon Fay during facility visit.

LPA Medina toured facility. Facility observed to have adequate staffing on site. All common areas of facility have adequate seating and lighting for all residents. Kitchen toured, facility has adequate food supply available and continues to receive multiple deliveries weekly for fresh vegetables, dairy, meat and canned goods. Fire extinguishers and current with a service date of 4/18/22.

The facility has a supply of Personal Protective Equipment (PPE) on site and available if needed.

LPA received copies of LIC 9020, current staff schedule, weekly menu, and memo to Forest Hill Family, Residents and Staff dated 10/17/22.

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: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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