<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 11/22/2022
Date Signed: 11/22/2022 01:18:04 PM


Document Has Been Signed on 11/22/2022 01:18 PM - 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:
11/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Sharon FayTIME COMPLETED:
01:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/22/22, 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.

Facility toured. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food available for residents. Facility receives food deliveries for both perishable and non-perishable foods 3 to 4 times weekly.

LPA spoke with with Sharon Fay, Administrator. LPA observed residents having lunch during facility. Currently, facility has 2 residents receiving hospice services.

LPA received memos to Residents, Family, and staff dated 11/14/22 & 11/17/22 and facility menu for week of November 20th-26th, 2022.

No changes in resident roster or staffing at the time of this visit.

No deficiencies observed or cited during visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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 1