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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700245
Report Date: 07/09/2021
Date Signed: 07/09/2021 10:52:49 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: 58DATE:
07/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sarah EhretTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conduced an unannounced visit to conduct a Case Management - Health Checks visit and met with Sarah Ehret Executive Director (ED) and Joey Garcia Director of Maintenance. LPA explained the purpose of the visit.

LPA toured the facility inside and out. Facility interior room temperature was 74 degrees Fahrenheit (F). Water temperature in AL resident bathroom measured at 113.9 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 watermelons, bananas, pineapple, grapes, strawberries and cantaloupe. Lunch prep was in process. Staff preparing fish and chips with fresh cod and Manhattan Claim chowder. Fresh fruit cups and salad prepared as side dishes.

At 10:15am in A LPA observed 1 LVN, 2 Certified Nurse Assistants (CNAs) and 1 housekeeper present.
Also, LPA observed 3 administrative staff, 1 receptionist, 1 chef, 5 kitchen staff, 1 dining room server, 2 laundry room attendants. Laundry room was in operation. Based on review of staff schedule and observations, staffing was sufficient.

LPA interviewed Executive Director. Resident services being provided include direct care needs, food service, housekeeping, medication management and activities. Today a Scenic Walk is scheduled for 1:30pm. LPA obtained copies of Town Hall Meeting Minutes dated 7/2/2021, Weekly Resident Memo dated 7/6/2021, Resident Roster dated 7/9/2021, and Menu for the week of July 4-10th, 2021.

No deficiencies cited during this visit per the California Code of Regulations Title 22.
Report review with Sarah Ehret Executive Director and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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