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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 04:01:21 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Darius StirTIME COMPLETED:
04:00 PM
NARRATIVE
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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 visit on 12/06/2023, it was discussed to submit LIC 624 regarding R1's hospitalization as LPA observed R1 being transported by Metro Fire. LPA has not receive the requested document.

Additionally, on 12/06/2023, LPA requested a copy of liability insurance from Administrator. LPA then was informed day prior to today's visit that facility does not have an active liability insurance. Administrator stated license was not received. LPA observed a copy of license was provided on 12/28/2022 by Adult and Senior Program Centralized Application Bureau.

During today's visit, LPA provided a physical copy to Administrator. Technical Support was offered and declined by Administrator.

Deficiencies cited. Please see LIC 809-D.

Exit interview and a copy of the report and appeal rights 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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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 (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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2023
Section Cited
CCR
87211(a)(1)(D)

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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:
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-Licensee will submit the requested LIC 624 for R1 to LPA Yang.
-Additionally, Licensee will review CCR 87211 Reporting Requirement and notify LPA once completed.
- POC is due by Friday, December 22, 2023.
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Based on interview, Licensee did not comply with the section cited above as Licensee did not submit an incident report for R1 to Licensing as discussed on 12/6/2023, which poses a potential risk to residents in care.
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Type B
01/05/2024
Section Cited
HSC1569.605

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ยง1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
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Licensee was provided a physcial copy of license.
Licensee will submit proof of facility liability insurance to LPA Yang by January 5, 2024.
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Based on interview, Licensee did not comply with the section cited above as Administrator informed LPA via email that facility does not have liability insurance, which poses a potential 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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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