345002940-10-31-2022-25-AS-CYAG-CKQQAH-20221031115957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:00:07 PM

Document Has Been Signed on 10/31/2022 12:00 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	MADISON SQUARE SENIOR LIVING II		FACILITY NUMBER:	345002940
ADMINISTRATOR:	DARIUS O. STIR		FACILITY TYPE:	740
ADDRESS:	3120 COLORADO ST.		TELEPHONE:	(916) 757-0918
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 0	DATE:	10/31/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Darius Stir		TIME COMPLETED:	12:10 PM

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	On 10/31/2022, Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a Pre- Licensing visit. The facility has a fire clearance for 2 ambulatory and 4 non-ambulatory residents. Room #1 is approved for one (1) ambulatory, room #2 is approved for two (2) non-ambulatory, room #3 is approved for one (1) ambulatory, and room #4 is approved for two (2) non-ambulatory. LPA observed Administrator Certificate #6035251740 to be present with expiration date of 05/17/2023. The facility has (0) residents at this time. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) resident bedrooms, and three (3) resident shared bathrooms. LPA observed facility to be under renovation. The common areas and residents bedroom are not fully furnished. Bathrooms are still under cosmetic renovation, mirrors and hand-washing signs will need to be installed. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and and groceries to be present on the counter. Administrator informed LPA he just finished his grocery shopping. LPA advised Administrator to have 2+ days of perishable and 7+ days of non-perishable foods. LPA informed Administrator to designate three location for a locked and secured space for sharps, toxics and medications. LPA observed smoke detector to be present and operational but no carbon monoxide detectors. LPA informed Administrator that the facility needs operational carbon monoxide detectors to be installed. Administrator re-informed LPA that the facility is still under renovation as the condition of the facility was in distressed. LPA observed first aid kit to be recently purchased. LPA informed Administrator to post CCL's LET-US-NO poster at entrance, and set up a visitor sign-in area with PPE's. Please continue on LIC 809-C...

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MADISON SQUARE SENIOR LIVING II	FACILITY NUMBER: 345002940
	VISIT DATE: 10/31/2022

NARRATIVE

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Continued from LIC 809...

LPA toured the laundry room with Administrator. Adminsitartor informed LPA he will be replacing the door knob for a locked door knob. Administrator informed LPA the outside door in Room #3 has a crack and will be replaced as well.

LPA toured and observed the garage space to be cluttered and in disrepair. Administrator again re-informed LPA that the facility is still under cosmetic fixation as it was left in poor conditions when Administrator took over lease.

Administrator informed LPA the dining table chair to not be properly screwed at the moment. LPA observed the temperature of the facility to be 65*, the temperature will need to be at an appropriate temperature during operation. LPA observed the facility to have an operational phone. LPA observed the facility to have (2) new fire extinguishers but with no date of service tagged. LPA informed Administrator it will need to be serviced and dated.

LPA informed Administrator a case management visit or video conference will need to be conducted as a follow up to ensure all items has been corrected.

Component III was waived as Administrator currently has another facility licensed by CCLD. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval once requested items have been received. CAB will further contact applicant on final status of application.

As a result of today's inspection, no deficiencies were cited.

Exit interview conducted. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC809 (FAS) - (06/04)

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