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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600753
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:12:55 PM

Document Has Been Signed on 07/11/2022 12:12 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHESTNUT HOUSEFACILITY NUMBER:
415600753
ADMINISTRATOR:DAYEH, ANAFACILITY TYPE:
740
ADDRESS:590 CHESTNUT STREETTELEPHONE:
(650) 594-1464
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 6CENSUS: 5DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Mihael DayehTIME COMPLETED:
12:25 PM
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On July 11, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front door. LPA met with Caregiver, Merlinda Datlag and Administrator, Mihael Dayeh joined shortly thereafter. LPA explained the purpose of the visit. LPA was not screened at entry point and Caregiver was unable to provide screening log documentation for staff and residents.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a two story facility; 3 bedrooms and 2 bathrooms on the first floor and 2 bedrooms, 1 staff room and 1 bathroom on the second floor. LPA toured the first floor bedrooms, two are observed to be private rooms and one is observed to be a shared room with beds 6ft apart from one another. Bathrooms were equipped with liquid soap, paper-towels and hand-washing signs. LPA advised caregiver to ensure shared bathrooms have a trash can with a fitted lid and to ensure there are no bar soaps and hand/bath towels.

LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature was maintained, lighting is sufficient for comfort. LPA toured the kitchen and medications, toxins and sharps are stored appropriately and inaccessible to residents. First aid kit was observed to be completed. LPA observed 2 day perishable and 7 day non-perishable present.

LPA toured the second floor resident bedrooms; both used as private rooms. LPA observed the bathroom, clean and odor-free. LPA advised caregiver to remove bar soaps and hand towels. Staff room and bathroom were observed. Extra linen was present. (CONT. TO 809C).
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHESTNUT HOUSE
FACILITY NUMBER: 415600753
VISIT DATE: 07/11/2022
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LPA toured the backyard, and it was clear from obstruction Garage was observed to have two fridges equipped with extra food. Washer and dryer was observed to be in good repair. According to caregiver, the garage door remains locked at all times.

Infection control practices are present: entry procedures, face coverings, COVID-19 signage posted throughout the facility, and 30-day PPE supply.

LPA requests the following forms to be submitted to CCLD by 7/18/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC610E Emergency Disaster Plan
  • Administrator Certificate


Report is reviewed with Administrator, Mihael Dayeh, and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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