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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:01:59 PM

Document Has Been Signed on 11/26/2024 12:01 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 LIVINGFACILITY NUMBER:
342700860
ADMINISTRATOR/
DIRECTOR:		STIR, DARIUSFACILITY TYPE:
740
ADDRESS:4517 CYCLAMEN WAYTELEPHONE:
(279) 777-5875
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:DariusTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 11/26/24, an in office Non-compliance conference was held.
Present were: Regional Manager, Alycia Rayner, Licensing Program Manager, Maribeth Senty, Licensing Program Analyst, Kevin Mknelly, Administrator, Darius Stir(representing licensee Madison Square Senior Living LLC).

A non-compliance plan was developed with the licensee on today's date as it relates recent compliance history.

The licensee was in agreement with the drafted non-compliance plan.

No new citations are issued as a result of today's meeting.

Documents to be emailed and signed copies returned.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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