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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:17:29 PM


Document Has Been Signed on 11/17/2023 03:17 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 LIVINGFACILITY NUMBER:
342700860
ADMINISTRATOR:STIR, DARIUSFACILITY TYPE:
740
ADDRESS:4517 CYCLAMEN WAYTELEPHONE:
(279) 777-5875
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:CaregiverTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived on 11/17/23 for the purpose of conducting Plan of Correction (POC) inspection for deficiencies issued on 10/31/23. LPA was greeted by caregiver. LPA spoke with the Administrator by phone.

On 10/31/23 deficiencies were cited for a fire clearance and a criminal record clearance violation.
At this time, clearance issues are resolved and all staff have verified clearance to work at the facility.
R2 continues to reside in a room fire department cleared for ambulatory residents only. This failure to correct has exceeded 10 days therefore the citation is to be reissued without civil penalty for the failure to correct.

LPA discussed annual fees past due on 10/31/23. The fees have not been paid at this time, therefore a citation is issued.

Administrator is still in process of correcting resident and staff file issues cited. The plan of correction dates for those deficiencies is 11/21/23.

LPA also advised Administrator to have LIC 308 designations of staff in place for times they are not present.

An exit interview was conducted with caregiver, MS. A copy of the report was provided and appeal rights were given. Licensee/Administrator to submit Plan of Corrections by due date.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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 2


Document Has Been Signed on 11/17/2023 03:17 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: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2023
Section Cited
CCR
87202(a)(1)

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(a) All facilities shall maintain a fire clearance approved... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify ... (1) Nonambulatory persons.
This requirement is not met as evidenced by: Based on observation and records
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Licensee will provide proof that R2 has been moved to a room cleared for non-ambulatory residents by the POC date of 11/18/23.
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 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.
This poses an immediate risk to residents.
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Type B
11/20/2023
Section Cited
CCR87156(a)

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Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
This requirement was not met based on records and interview.
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Licensee will submit proof of payment to CCL by the POC date of 11/20/23.

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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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2