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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 07/01/2021
Date Signed: 07/06/2021 08:28:41 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: 54DATE:
07/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Sarah EhretTIME COMPLETED:
01:10 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, laundry room, Fireside Lounge, and Assisting Living (AL) and Independent Living (IL) areas. Facility interior room temperature was 76 degrees Fahrenheit (F). Water temperature in AL common area Bathroom measured at 114.8 degrees F. Bathrooms 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 nonperishable food supply. LPA observed fresh fruit of bananas, pineapple, raspberries, blueberries and strawberries. Lunch prep was in process. Staff preparing from scratch orange chicken with rice and fresh green beans. Fresh fruit cups and lettuce wedges prepared as side dishes. Baker was preparing a cake dessert.

At 12:00pm LPA observed meal service in AL dining area. In AL LPA observed Administrator, 3 Certified Nurse Assistants (CNAs) and 1 housekeeper present.

Also, LPA observed 3 administrative staff, 1 receptionist, 1 chef, 5 kitchen staff, 1 host, 2 dining room servers, 2 laundry room attendants and 2 maintenance staff on site. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

LPA interviewed Executive Director and Administrator. Services provided include activities of daily living, food service, housekeeping, medication management and activities. On 7/5/2021 Jazz Pianist Bob Phillips is scheduled to perform. Fourth of July Picnic to be held on the outdoor patio area. Town Hall meeting with residents scheduled for 7/2/2021.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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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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: 07/01/2021
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LPA obtained copies of 6/28/2021 Weekly Update Memo to Residents, Family & Staff, Resident dated July 2021, update to Register of Facility Residents ( LIC9020), Staff Schedule for July 2021, and Menu for the week of July 1-10th, 2021.

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

Report review with Sharon Fay Administrator and a copy emailed due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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