Community Care Licensing

Document Has Been Signed on 10/31/2023 03:54 PM - It Cannot Be Edited

FACILITY NAME:	MADISON SQUARE SENIOR LIVING		FACILITY NUMBER:	342700860
ADMINISTRATOR:	STIR, DARIUS		FACILITY TYPE:	740
ADDRESS:	4517 CYCLAMEN WAY		TELEPHONE:	(279) 777-5875
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY: 6		CENSUS: 4	DATE:	10/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Casregiver		TIME COMPLETED:	04:00 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING	FACILITY NUMBER: 342700860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Type A

Section Cited

CCR

87202(a)(1)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in1 of 1 residents (R2) currently is non-ambulatory residing in a room cleared for ambulatory only which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee will provide proof that either R2 has been re assessesed to be ambulatory or that R2 has been moved to a room cleared for non-ambulatory residents by the POC date of 11/1/23.

Type A

Section Cited

HSC

1569.17(b)(1)(B)

(B) Any person, other than a client, residing in the facility. Residents of unlicensed independent senior housing facilities that are located in contiguous buildings on the same property as a residential care facility for the elderly shall be exempt from these requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, the licensee did not comply with the section cited above in 2 of 2 staff (s1 and S2) do not have a clearance prior to work in the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof that S1 and S2 have moved from the home unless and untill criminal record clearance is received. Licensee will also submit a LIC 500 to confirm adequate staffing by cleared staff. POCs due by 11/1/23

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING	FACILITY NUMBER: 342700860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 of 2 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	LIC 311 provided. Licensee will complete staff files for all employees by the POC date. To be cleared by POC visit.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING	FACILITY NUMBER: 342700860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 2 of 2 staff (S1 and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Licensee will complete required staff training by the POC date of 11/21/23 To be cleared by visit.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING	FACILITY NUMBER: 342700860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 4 of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Licensee was provided LIC 311 of required documents. Licensee will notify LPA of completed files by the POC date of 11/21/23. To be cleared by POC visit.

Type B

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 4 of 4 client files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Licensee will notify LPA of completed files by the POC date of 11/21/23. To be cleared by POC visit.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023