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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700860
Report Date:
10/31/2023
Date Signed:
10/31/2023 03:54:34 PM
Document Has Been Signed on
10/31/2023 03:54 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
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
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/31/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Caregiver and explained the purpose of the visit. Administrator was notified and arrived to assist.
LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured the following issued were discussed and plans of correction established: R2 is non-ambulatory yet resides in a ambulatory only room. Licensee will make arrangements to move R2 to a vacant room. LPA discussed the process for modifying room three to be fire clearance compliant for non-ambulatory residents. The complaint poster was not observed.
LPA reviewed resident files. 4 of 4 files are incomplete for various required forms. Medication files are also incomplete.
LPA reviewed staff files. 2 of 2 files are incomplete for forms and training. S1 and S2 did not have required criminal record clearance for CA assisted living. Arrangements were made to secure clearance and transfer staff to work at the home.
As a result of this inspection, the following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview conducted. Report and appeal rights provided.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
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
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
16
Document Has Been Signed on
10/31/2023 03:54 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
MADISON SQUARE SENIOR LIVING
FACILITY NUMBER:
342700860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(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
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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
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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)
Licensing
(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
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2
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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
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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
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
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
LIC809
(FAS) - (06/04)
Page:
2
of
16
Document Has Been Signed on
10/31/2023 03:54 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
MADISON SQUARE SENIOR LIVING
FACILITY NUMBER:
342700860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(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
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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
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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
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
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
LIC809
(FAS) - (06/04)
Page:
3
of
16
Document Has Been Signed on
10/31/2023 03:54 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
MADISON SQUARE SENIOR LIVING
FACILITY NUMBER:
342700860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(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
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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
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2
3
4
Licensee will complete required staff training by the POC date of 11/21/23
To be cleared by visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
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
LIC809
(FAS) - (06/04)
Page:
4
of
16
Document Has Been Signed on
10/31/2023 03:54 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
MADISON SQUARE SENIOR LIVING
FACILITY NUMBER:
342700860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(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
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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
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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)
Incidental Medical and Dental Care Services
(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
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2
3
4
Licensee will notify LPA of completed files by the POC date of 11/21/23.
To be cleared by POC visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
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
LIC809
(FAS) - (06/04)
Page:
5
of
16