<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600064
Report Date: 11/06/2024
Date Signed: 02/19/2025 11:11:11 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2024 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240826162856
FACILITY NAME:MAITRI RESIDENTIAL CARE (FPLWA)FACILITY NUMBER:
385600064
ADMINISTRATOR:MICHAEL ARMENTROUTFACILITY TYPE:
736
ADDRESS:401 DUBOCE AVENUETELEPHONE:
(415) 558-3000
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:15CENSUS: 12DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mollie HerzigTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Non-resident resided in facility without criminal record clearance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on interviews with clients and staff, this allegation is determined to be unsubstantiated.
Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.
Residents are allowed to have visitors from 8 am to 9 pm. Facility does not permit residents to have overnight guests unless approval is granted by facility management; this policy is acknowledged by all residents upon admission.
A visitor of client #1 was known by staff to have stayed overnight over the summer, on at least one occasion. Client did not seek approval for the overnight guest, nor was staff aware of this, until after the fact. When client #1 allowed a visitor to remain after 9pm, administrator spoke to client and reminded him of the rules regarding visiting hours and prohibition of overnight guests. Modified visitation hours for client #1--12 pm to 5 pm--were imposed.
Despite information provided by clients and staff that a non-resident without criminal record clearance stayed overnight in facility, staff were not aware of the visitor's presence at the time. Therefore, they were unable to prevent the visitor from remaining in facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20240826162856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/07/2024
Section Cited
CCR
87819(b)(3)
1
2
3
4
5
6
7
CRIMINAL RECORD CLEARANCE
The following persons and any other adults specified in H & S Code Section 1568.09 shall be required to be fingerprinted and comply with applicable criminal record requirements.
- Any person, other than a resident, residing in the facility.
1
2
3
4
5
6
7
Plan of correction shall be submitted to CCLD BY DUE DATE
8
9
10
11
12
13
14
This requirement was not met, as at least one unknown visitor of client #1 stayed overnight in facility, which posed an immediate health, safety or personal rights risk to clients in care. Licensee failed to ensure that all persons residing in facility maintain criminal record clearance.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2024 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240826162856

FACILITY NAME:MAITRI RESIDENTIAL CARE (FPLWA)FACILITY NUMBER:
385600064
ADMINISTRATOR:MICHAEL ARMENTROUTFACILITY TYPE:
736
ADDRESS:401 DUBOCE AVENUETELEPHONE:
(415) 558-3000
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:15CENSUS: 12DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mollie HerzigTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Residents were able to use drugs while in the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on review of facility records and interviews with clients and staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

Clients #1 and #2 were alleged to have taken illegal drugs in the facility. Both denied that they have. Both clients signed acknowledgement of facility's Expectations and Responsibilities, that they will not possess or use illicit substances, use or sell illegal drugs, or possess drug paraphernalia.
However, interviews with staff were inconsistent about knowing or having suspicions that clients were using drugs in the facility. While no one said they witnessed illegal drug use in facility, unidentified smoke was observed by staff and clients emanating from client's room.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3