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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:00:33 PM


Document Has Been Signed on 11/17/2022 03:00 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 IIFACILITY NUMBER:
345002940
ADMINISTRATOR:DARIUS O. STIRFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 757-0918
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee, Darius StirTIME COMPLETED:
03:15 PM
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On 11/17/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility announced to conduct a case management visit to complete the pre-licensing inspection. Prior to initiating today's visitation, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA was not screened prior to entering the community.

LPA and Licensee toured the interior and exterior of the facility and deficiencies were observed. LPA observed all four (4) bedrooms to not be fully furnished as stated in Title 22, 87307 (a)(3)(B) : Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

LPA informed Licensee that facility needs to screen all visitors upon entry, so facility will need a sign in table, equipped with PPE's. LPA observed a carbon monoxide detector to be removed by the entrance of Bedroom #4, LPA informed Licensee the carbon monoxide will need to be re-installed in the ceiling.

LPA observed the exterior of the facility to have a clear pathway, LPA advised Licensee to have locks on the door to prevent residents from entering the storage/garage as it is clutter with gardening tools. LPA informed Licensee the facility will need 2+ days of perishable food and 7+ days of non-perishable foods prior to admitting the first resident.

Once deficiencies are corrected, Licensee is to submit photos to LPA by 11/24/2022. Comp III was waived by Licensee as he is aware of his responsibilities for facility operation as Licensee has another facility.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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