<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:36:06 AM


Document Has Been Signed on 11/30/2023 10:36 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:
11/30/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Darius StirTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Manager (LPM), Maribeth Senty, and Licensing Program Analyst (LPA), Kevin Mknelly, conducted a remote office meeting with Administrator via Zoom conference to discuss recent compliance issues and offer further assistance if needed.

In the meeting today, LPM and LPA reviewed, with Mr. Stir, the citations and advisories issue to the licensee on visits dated 10/31/23 and 11/17/23. All plans of corrections have been completed to date.

The licensee is currently in compliance with regulatory requirements.

The regional office offered Mr Stir, Technical Support Program (TSP) consultation to further review and advise on medication administration and procedures as well as any other other issues identified with the licensee that may be of benefit to continued success. Mr. Stir accepted the offer. The Regional Office (RO) will submit a request to TSP.

As a result of this meeting no deficiencies were cited.

Copy of the report provided to Licensee via email with a request for return signed copy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 1