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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:01:54 PM


Document Has Been Signed on 12/14/2023 04:01 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
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: 4DATE:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Darius StirTIME COMPLETED:
02:00 PM
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On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator, Darius Stir, and explained the purpose of the visit.

During LPA's last visit on 12/06/2023, civil penalty was cited for criminal clearance. LPA realized civil penalty was generated under wrong Health and Safety Code (HSC) violation of §1569.618
Administration and management of residential care facilities; substituted qualifications; employee scheduling.
Today's visit, LPA assessed civil penalty under §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances. Appeal rights was provided, and the 15 day for civil penalty appeal will restart as of today.

Exit Interview conducted, and a copy of 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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