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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 10/31/2024
Date Signed: 10/31/2024 02:52:13 PM

Document Has Been Signed on 10/31/2024 02:52 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 LIVINGFACILITY NUMBER:
342700860
ADMINISTRATOR/
DIRECTOR:
STIR, DARIUSFACILITY TYPE:
740
ADDRESS:4517 CYCLAMEN WAYTELEPHONE:
(279) 777-5875
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:caregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/31/24, LPA Kevin Mknelly met with caregiver to conduct a Plan of Correction (POC) visit. Administrator was contacted by phone by LPA and informed of the reason for the visit.

In conversation by LPA ,with the Administrator, Administrator stated that updated LIC 602s for identified residents have not been completed yet ,nor have appointments been made.

On 10/9/24 the following citations were issued with plans of correction dates by 10/25/24:
87458(b)(1) Medical assessments- requires a physical assessment by a physician. It was found that 2 residents' LIC602s did not contain some examination information and were conducted remotely by a physician assistant (PA). Licensee agreed to obtain LIC602s from a physician's physical exam of the two residents and provide copies to LPA by the POC due date of 10/23/24. To date the exams have not been conducted.

The POCs may be cleared by confirmed assessment appointments submitted to LPA.

Licensee informed in this report that civil penalties may continue to accrue at $100 per day until the citation plans of corrections are completed.

As a result of this visit, no additional deficiency is noted. Civil Penalties for failure to correct have been issued.

Report reviewed. Copy of the report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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