345002940-9-19-2024-59-AS-KHOS-D9EGMA-20240924052735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002940
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:47:18 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240916115315

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: 6	DATE:	09/19/2024
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Darius Stir		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility failed to meet reporting requirements.

INVESTIGATION FINDINGS:

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On 9/19/2024, Licensing Program Analysts (LPAs) Yang and Mikkelson arrived unannounced at the facility to open and deliver the findings of the allegation cited above. LPAs met with caregiver, who then contacted Administrator who then arrived to the facility shortly afterwards.

Today's investigation, LPAs interviewed Administrator and condcuted file reviews.

Result of investigation is as follow, please continue on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240916115315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/19/2024

NARRATIVE

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LIC 9099-C...

Allegation: Facility failed to meet reporting requirements.
The Department investigated the following allegation. Based on interview conducted with Administrator on 9/19/2024, interview revealed that there has been a few recent falls. R1 had a fall a day prior to LPAs' visit who then was sent out to the emergency room for evaluation. Interview revealed that R1's family member was notified but LIC 624 UNUSUAL INCIDENT/INJURY REPORT has not been submitted to Licensing yet. Interview with Administrator further revealed that R2 had a fall on 08/24/2024, where R2 had a nose bleed. Administrator contacted R2's responsible party and was asked to not send R2 out for evaluation. Administrator stated LIC 624 UNUSUAL INCIDENT/INJURY REPORT was not submitted to Licensing regrading this incident. Based on Title 22 Section 87211, facility is required to provide written report to Licensing Division within seven days of occurrence.

Based on the allegation, facility failed to meet reporting requirements, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D.

$250 repeated violation civil penalty assessed as facility was cited on 12/14/2023 for the same deficiency.

Exit interview conducted and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240916115315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee is to submit a statement of understanding of the reporting requirements of 22 CCR Section 87211. POC is due 10/4/2024, failure to provide POC by POC due date may result to $100 civil penalty per day until received/corrected.
	8 9 10 11 12 13 14	Based on file review and interview, Licensee did not comply to the section cited above as Licensee stated LIC 624 was not submitted for R2 for an incident that occurred on 08/24/2024, which poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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