342700860-10-12-2022-25-AS-DAWL-CK5R64-20221012124406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 10/12/2022
Date Signed: 10/12/2022 12:44:16 PM

Document Has Been Signed on 10/12/2022 12:44 PM - It Cannot Be Edited

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 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: 6	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Darious Stir, Administrator		TIME COMPLETED:	12:57 PM

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On October 12, 2022, at 11:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required Annual Inspection. LPA met with Darius Stir the administrator and informed him the reason for the visit.
Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore a mask for Personal Protective Equipment (PPE).

The administrator's Certificate is valid and expires 5/17/2023.

The current census is .6 The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 73 degrees F which is within range.

The facility has not had Covid-19 as to date.

Darius and LPA completed the Infectious Control questionnaire with no issues or concerns.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food.

To continue see 809-C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 342700860
	VISIT DATE: 10/12/2022

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The facility is a one story home with a loft and 4 bedrooms and 3 bathrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. All rooms had the required items of furniture. Windows did not have screens. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use and in compliance at this time. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. LPA observed shaded areas in the backyard. Passageways are free of obstruction and potential hazards.

The home directly behind the facility belongs to the administrator's brother and is a facility as well. There is no back fence between the homes. The other facility is Nelus Care Home II, which is also on LPA's caseload.

Per California Code of Regulations Title 22, No citations were issued.

An exit interview was conducted and a copy of this report was given to Darius.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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