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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600753
Report Date: 07/01/2024
Date Signed: 07/01/2024 10:24:19 AM


Document Has Been Signed on 07/01/2024 10:24 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
SAN BRUNO RO, 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: 2DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Merlinda DatlagTIME COMPLETED:
10:45 AM
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On 7/1/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Care Staff Merlinda Datlag. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed a resident in the living room watching tv. While touring the facility it was observed that the room temperature was at 74 deg F. Hot water was also tested in the bathrooms and the temperature was 120 deg F. The residents have adequate amount of linens and care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every month. LPA observed sharps, toxins and chemicals to be locked and inaccessible to residents.

Two resident records and two staff records were reviewed. Resident records are updated, complete and signed. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested to email Liability Insurance, LIC610 and LIC500.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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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