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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:14:48 AM


Document Has Been Signed on 11/29/2022 10:14 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:
11/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Sharon FayTIME COMPLETED:
10:12 AM
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On 11/29/22, Licensing Program Analysts (LPA) M. Medina conducted a Case Management visit. COVID-19 screening protocols continued to be in place, LPA screened upon entrance. All staff observed to be wearing face mask throughout facility.

LPA spoke with Sharon Fay, Administrator. LPA observed residents in Assisted Living in activity room participating in activities. Currently, facility has 2 residents receiving hospice services.

LPA received memos to Residents, Family, and staff dated 11/23/22.

One new resident and no changes in 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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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