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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:03:25 PM


Document Has Been Signed on 02/15/2024 04:03 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: 5DATE:
02/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Caregiver and SupervisorTIME COMPLETED:
04:05 PM
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On 2/15/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Proof of Correction (POC) visit. LPA met with caregiver, Princess Allen, who notified Supervisor, Samantha Shaw Camacho, who arrived to the facility shortly afterwards.

Today's visit, LPA conducted a file review of two personnel and two staff files. Additionally, LPA conducted an inspection of the kitchen area to ensure there is a secured storage space for sharps.

LPA cleared the following deficiencies:

- 87211 Reporting Requirements
- §1569.605 Liability insurance
- 87412 Personnel Records
- 87506 Resident Records
- §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances
- 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling
- 87309 Storage Space
- 87202 Fire Clearance

LPA informed Supervisor a copy of POC clearance will be mailed to facility.

LPA and Supervisor discussed Licensee submitting LIC 200 and facility sketch to request fire clearance of six non-ambulatory residents.

No deficiencies cited. Exit interview conducted and a copy of the report will be emailed.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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