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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 11/28/2023
Date Signed: 11/30/2023 08:14:27 AM


Document Has Been Signed on 11/30/2023 08:14 AM - 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: 5DATE:
11/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived on 11/28/23 for the purpose of conducting Plan of Correction (POC) inspection for deficiencies issued on 10/31/23. LPA was greeted by caregiver. Administrator arrived to assist with the visit.

On 10/31/23 deficiencies were cited for resident and staff files being incomplete.

LPA reviewed 4 resident files and 2 staff files. All files reviewed were complete for required documents.
A new resident was admitted on 11/27/23. That file was in process of being assembled and was not reviewed by LPA.

As a result of this visit, the plans of corrections (POC) are cleared and POC letters provided.

No deficiencies are sited as a result of this visit.

An exit interview was conducted with caregiver, MS. A copy of the report was provided

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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