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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600064
Report Date: 12/02/2021
Date Signed: 12/02/2021 10:39:23 AM

Document Has Been Signed on 12/02/2021 10:39 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MAITRI RESIDENTIAL CARE (FPLWA)FACILITY NUMBER:
385600064
ADMINISTRATOR:SUSAN CANAVANFACILITY TYPE:
736
ADDRESS:401 DUBOCE AVENUETELEPHONE:
(415) 558-3000
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 15CENSUS: 13DATE:
12/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Clinical Director, Molly HerzigTIME COMPLETED:
10:45 AM
NARRATIVE
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On 12/2/2021, Licensing Program Analyst (LPA) Murial Han conducted an announced follow-up visit from the Annual Inspection. LPA Han was properly screen at the front entry. LPA met with the Clinical Director, Molly Herzig and explained the purpose of today's visit.

On 9/22/2021, during an on-site visit, LPA Han was informed by one of the directors that the facility has a new Administrator. LPA Han explained the process of change of Administrator and the required documents.

On 11/16/2021, during the Annual Inspection, there was no documents available for LPA Han to review and to verity of the new Administrator, therefore, during the exit meeting, LPA Han reminded the facility's directors that the Department has not received the requested documents and the documents shall be submitted by 11/19/2021.

Furthermore, on the same day at 4:30PM, LPA Han provided the facility in writing a list of the documents that is needed to change the Administrator and links to the Regulations for additional resources.

On 11/17/2021, Licensing Program Manager (LPM), Julio Montes reminded the facility in writing to submit the required documents and LPM Montes included a list of the documents that is required to proceed with change of Administrator.

On 11/23/2021, LPA reminded the Directors of the facility that the Department has not received any of the requested documents.

Based on observations and interviews, the facility failed to provide required documents to the Department for the verification of the Administrator-Qualifications and Duties. Deficiency of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Clinical Director, and Appeal Rights provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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Document Has Been Signed on 12/02/2021 10:39 AM - It Cannot Be Edited


Created By: Murial Han On 12/02/2021 at 10:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MAITRI RESIDENTIAL CARE (FPLWA)
FACILITY NUMBER: 385600064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/16/2021
Section Cited
CCR
87864

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Administrator-Qualifications and Duties...This requirement is not met as evidenced by the facility failed to provide documents to the Department for verification of the Administrator's qualifications after
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The facility director(s) will review Title 22, Division 6 Chapter 8.5 Article 06. Continuing Requirements 87864 Administrator- Qualifications and Duties and will submit a signed written document acknowledging
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several verbal and written reminders from the Department which poses a potential risk to client in care.
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that this regulation was reviewed. The facility will submit all the required documents by the plan of due date 12/16/2021.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Julio Montes
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
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