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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 10/12/2020
Date Signed: 10/12/2020 04:05:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MADISON SQUARE SENIOR LIVINGFACILITY NUMBER:
342700860
ADMINISTRATOR:STIR, DARIUS O.FACILITY TYPE:
740
ADDRESS:4517 CYCLAMEN WAYTELEPHONE:
(916) 757-0918
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 0DATE:
10/12/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Darius StirTIME COMPLETED:
03:50 PM
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LPA Hiratsuka, called and spoke to Administrator Darius Stir. Due to COVID-19 and precautionary measures, this visit was conducted by phone. This was a follow-up for the Face-Time pre-licensing visit Administrator had with LPA Gasendo, had on 10/08/2020.

Administrator emailed photos of a disaster plan, covid 19 posters on front door, receipt of brand new fire extinguisher, PPE equipment, and a list of emergency contact information for the staff. This facility has now met the requirements to be licensed.

LPA Hiratsuka, and Administrator discussed several items.


LPA is going to forward this report and LPA Gasendo's report to the applications specialist for their review.


LPA is going to email a copy of this report to Administrator and Administrator is to sign, and email a copy back to LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
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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