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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 10/14/2021
Date Signed: 10/14/2021 11:42:10 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MADISON SQUARE SENIOR LIVINGFACILITY NUMBER:
342700860
ADMINISTRATOR:STIR, DARIUSFACILITY TYPE:
740
ADDRESS:4517 CYCLAMEN WAYTELEPHONE:
(279) 777-5875
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Darius Stir, AdministratorTIME COMPLETED:
09:50 AM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the Administrator, Darius Stir, to conduct an annual required and post licensing visit.

For more information on the post licensing visit please see LIC 809 dated 10/14/21.

No deficiencies cited for the post licensing visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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