Forest Hill Manor Health Center
551 Gibson Avenue, Pacific Grove, CA 93950 · Monterey County · 26 certified beds · avg 25 residents/day · certified since Sep 23, 2010
Part of chain: BVHC, LLC (12 facilities, chain avg rating 3.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Oct 1, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 10, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Oct 1, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 25, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 23, 2024 | F · Potential for harm, facility-wide | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jan 23, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 23, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jan 23, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 8 | 0 | E |
| 2024 | 12 | 0 | F |
| 2025 | 7 | 1 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278.
| Date | Type | Amount / length |
|---|---|---|
| Oct 1, 2025 | Fine | $8,278 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.27 | 4.31 | 3.95 | top 40% in California; top 30% in the U.S. |
| Registered Nurse hours | 0.76 | 0.61 | 0.69 | top 19% in California; top 30% in the U.S. |
| Weekend total nurse staffing | 3.68 | 3.90 | 3.50 | bottom 45% in California; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.51 | 0.48 | top 37% in California; top 39% in the U.S. |
| Total nursing staff turnover (%) | 44.4 | 36.7 | 45.8 | bottom 27% in California; top 49% in the U.S. |
| RN turnover (%) | 40.0 | 38.1 | 42.9 | bottom 47% in California; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.04, RN 0.90, weekend 4.35. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: —/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Acosta, Mariah | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/16/2025 |
| Acosta, Mariah | Individual | ADP of the SNF | NOT APPLICABLE | 02/16/2025 |
| Calabazaron, Redentor | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/14/2022 |
| Calabazaron, Redentor | Individual | ADP of the SNF | NOT APPLICABLE | 02/14/2022 |
| Chinthakindi, Ravi | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/21/2022 |
| Chinthakindi, Ravi | Individual | ADP of the SNF | NOT APPLICABLE | 11/21/2022 |
| Fuentes, Ray | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/06/2022 |
| Fuentes, Ray | Individual | ADP of the SNF | NOT APPLICABLE | 12/06/2022 |
| Pique, Jannet | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/23/2023 |
| Pique, Jannet | Individual | ADP of the SNF | NOT APPLICABLE | 05/23/2023 |
| Taylor, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/08/2023 |
| Taylor, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 05/08/2023 |
| Thapa, Nischal | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/06/2024 |
| Thapa, Nischal | Individual | ADP of the SNF | NOT APPLICABLE | 08/06/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Canterbury Woods | 0.0 mi | Pacific Grove, CA | ★★★★★ | 5/5 | |
| Oceanview Post Acute | 0.6 mi | Pacific Grove, CA | ★★★★★ | 4/5 | |
| Cypress Ridge Care Center | 1.5 mi | Monterey, CA | ★★★★☆ | 3/5 | |
| Monterey Post Acute | 1.6 mi | Monterey, CA | ★★★★☆ | 3/5 | |
| Westland House | 2.9 mi | Monterey, CA | ★★★☆☆ | 4/5 | |
| Carmel Hills Care Center | 4.3 mi | Monterey, CA | ★★★☆☆ | 2/5 | |
| Katherine Healthcare | 15.3 mi | Salinas, CA | ★★☆☆☆ | 2/5 | |
| Coastal Post Acute | 15.4 mi | Salinas, CA | ★★★★☆ | 3/5 | |
| Windsor the Ridge Rehabilitation Center | 15.4 mi | Salinas, CA | ★★★★★ | 4/5 | |
| Pacific Coast Post Acute | 15.8 mi | Salinas, CA | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555867.