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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005536
Report Date: 04/25/2022
Date Signed: 05/13/2022 01:42:34 PM


Document Has Been Signed on 05/13/2022 01:42 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MADSEN MANORFACILITY NUMBER:
507005536
ADMINISTRATOR:MELISSA BALDWINFACILITY TYPE:
740
ADDRESS:209 DOWNEY AVETELEPHONE:
(510) 415-6830
CITY:MODESTOSTATE: CAZIP CODE:
95354
CAPACITY:6CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melissa BaldwinTIME COMPLETED:
12:00 PM
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Unannounced case management visit made out to this facility on 04/25/2022 by Licensing Program Analyst (LPA) Charlie Yang and was met by the current facility designated Administrator, Melissa Baldwin, who was briefly interviewed.
Current census was 4 residents.
It was learned that this facility will be closing by the end of the month (April 2022) according to Melissa Baldwin. Notice was given to the families and responsible parties of the residents by the facility designated Administrator and Licensee by verbal means and email notifications back in late January and early February.
The facility designated Administrator stated that a copy of the Decision and Order was received and reviewed by herself and the Licensee, Carol Madsen, in its entirety which resulted in the decision to close this facility and relinquish the license.
The license for this facility was surrendered by the facility designated Administrator, Melissa Baldwin, along with a closure letter at this time to this LPA.
This LPA explained that a follow up will need to be made once all of the residents had moved out of this facility. The facility designated Administrator stated that she will contact this LPA once all of the residents had been relocated for the follow up visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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