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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:52:37 AM


Document Has Been Signed on 09/19/2024 11:52 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 LIVING IIFACILITY NUMBER:
345002940
ADMINISTRATOR:DARIUS O. STIRFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 757-0918
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Darius StirTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Yang and Mikkelson arrived unannounced at the facility to conduct a case management visit regarding a deficiency LPAs observed. LPAs met with caregiver who then contacted Administrator who then arrived to the facility shortly afterwards.

During LPAs visit, LPAs observed S1 to be working alone with residents in care. LPAs were informed S1 has been working at the facility since April 30, 2024. Based on file review, LPAs did not observe S1 to be associated to facility roster on Guardian. LPAs completed LIC 9182 with Administrator's signature to transfer S1's association to the facility.

LPAs and Administrator discussed fire clearance as Room 1 and Room 3 are approved for ambulatory only. LPAs reminded Administrator that residents with non-ambulatory status due to physical and/or mental condition cannot reside in Room 1 and Room 3 until cleared by Sacramento Metro Fire Department. Additionally, LPAs reminded facility that based on State Marshal laws and regulation, fire door are to remain closed at all times.

Deficiencies cited and civil penalty assessed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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Document Has Been Signed on 09/19/2024 11:52 AM - 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 II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87411(g)(2)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
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Licensee completed LIC 9182 for S1.
Licensee is to conduct an audit of facility roster and associate any additional staff needed to roster. Licensee is to inform LPA Yang by 10/4/2024 of completion.

Failure to correct by POC due date may result to $100 civil penalty per day until received/corrected.
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Based on observation, Licensee did not comply with the section as LPAs observed S1 to be working at the facility without a criminal clearance transfer associated to the facility, which poses a potential health and safety risk to residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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