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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600064
Report Date: 01/08/2025
Date Signed: 01/08/2025 02:43:58 PM

Substantiated


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
07/22/2024 and conducted by Evaluator Audrey Jeung
COMPLAINT CONTROL NUMBER: 14-AS-20240722104121
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: 9DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michael Armentrout and Molly HerzigTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Facility is in disrepair
- Staff are not properly disposing hazardous materials
INVESTIGATION FINDINGS:
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Based on information reported by and obtained from facility staff and residents, and observations made by LPAs, these allegations are substantiated. The preponderance of evidence standard has been met.
On 7/29/24, LPA Jeung observed that after turning on the water in the shower stall for 2 minutes, water pooled around the square drain under the shower head and took almost 3 minutes for water to drain completely.
Used gloves and soiled diapers/wipes were observed in uncovered waste containers. In room #2, a mirrored tri-door medicine cabinet over the sink observed with the left side mirror not secured to the cabinet and a 3 drawer chest of drawers, with 3 out of 6 pull handles missing, rendering the middle drawer unusable.
Window screens are observed not secured to windows on 11/6/24.
Hazardous waste is removed from clients' rooms in plastic bags and stored in a biohazard waste closet in covered plastic bins. However, the hazardous waste is observed in single bags, and is not double bagged. The storage closet is locked and there is a sign posted, "Caution--Biohazardous Waste Storage Area."
Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 4
Control Number 14-AS-20240722104121
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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
87887(a)
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BUILDINGS AND GROUNDS
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees, volunteers and visitors.
This requirement was not met, as shower drain was clogged, mirrored medicine
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Plan/proof of correction to be submitted to CCLD BY DUE DATE

Today, LPA observed that new windows and window screens have been installed throughout facility.
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cabinet in disrepair, dresser drawers missing handles, and window screens not secured. Licensee failed to ensure that facility was maintained in good repair, which posed a potential health, safety or personal rights risk to clients in care.
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Type B
01/22/2025
Section Cited
CCR
87895.5(a)
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INFECTION CONTROL REQUIREMENTS
Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required by subsection (a)(4)(A) with one resident and prior to an interaction with another resident.
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Plan/proof of correction to be submitted to CCLD BY DUE DATE
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This requirement was not met, as used gloves were observed in uncovered waste containers. Licensee failed to ensure that soiled gloves were discarded in covered waste container, which poses a potential health, safety or personal rights risk to clients in care.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20240722104121
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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
87889
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7
SAFETY AND SANITATION
Contaminated and hazardous waste... shall be disposed of by a hazardous waste company...at least twice a month or more often if needed...Contaminated and hazardous waste shall be double bagged...The exterior of the ...area
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Plan/proof of correction to be sent to CCLD BY DUE DATE.
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designated for storing the contaminated waste shall be clearly labeled"contaminated."
This requirement was not met, as hazardous waste observed in plastic bins in single plastic bags & closet not labeled "contaminated." This poses a potential health, safety or personal rights risk.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
07/22/2024 and conducted by Evaluator Audrey Jeung
COMPLAINT CONTROL NUMBER: 14-AS-20240722104121

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: 9DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michael Armentrout and Molly HerzigTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
- Facility is unsanitary
- Facility is malodorous
- Staff are not adhering to infection control protocols
INVESTIGATION FINDINGS:
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Based on interviews with clients and staff, as well as LPA's observations, these allegations are determined to be unsubstantiated. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

It was alleged that feces was present in shower, bathing facilities were not cleaned, and commode in shower room was not emptied, resulting in malodors. According to custodian manager, bathrooms are cleaned daily and commodes are emptied as needed by CNAs, who also empty biohazard waste containers. LPA spoke with several residents, who had no concerns about sanitation or odors.

Caregiving staff are certified nursing assistants and maintain valid certification from the CA Dept. of Public Health. In addition to DPH training upon hire regarding blood borne pathogens, staff receive ongoing training from facility RN on various topics that include proper use and disposal of gloves.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4