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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:11:38 PM


Document Has Been Signed on 12/13/2022 01:11 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:
12/13/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Darius StirTIME COMPLETED:
11:45 AM
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On 12/13/2022, Licensing Program Analyst (LPA) Cassie Yang conducted an announced virtual inspection with Licensee, Darius Stir, via FaceTime. This is a pre-licensing continuation inspection from previous visits conducted on 10/31/2022 and 11/17/2022.

During today's inspection, LPA observed Room #1 to be fully furnished. LPA advised Licensee to move the night stand to create a clear pathway to access the dresser. Licensee corrected this immediately. LPA observed Room #2 to be fully furnished with the required furniture. LPA observed the kitchen to have a locked space for sharps. Licensee informed LPA all toxins will be locked and secured in the laundry room, and medications will be centrally stored in the staff office room. In Room #3, LPA observed the room to be missing a night stand but it was corrected immediately. LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA advised Licensee to post 20 second hand washing signs in the bathrooms. LPA observed Room #4 to have the required furniture and observed the boxes in the walk-in closet to be removed/corrected. LPA toured the exterior of the facility, no obstructions was observed.

LPA informed Licensee facility should have a thorough COVID-19 screening on the visitor log such as yes/no questions for cough, fever, exposure. LPA also informed Licensee facility shall be equipped with at least 30 days of personal protective equipment such as mask, gloves, hand sanitizers, etc.

COMP III was waived during the inspection conducted on 11/17/2022. Deficiencies observed during today's inspection was corrected immediately by Licensee.

Exit interview conducted. A copy of the report was emailed to Licensee to sign.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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