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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700860
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:06:15 PM

Document Has Been Signed on 12/30/2024 03:06 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:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Shavel WilliamsTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 12/30/24, Licensing Program Analyst (LPA) Kevin Mknelly, and met with Administrator, Shavel Williams. Samantha Shaw was also present.

Licensee is in process of increasing non-ambulatory capacity for an additional, previously ambulatory only, room.

LPA inspected the home to insure ambulatory occupancy in the room under review.
Fire safety measures are in place. Licensee is still completing Fire Marshal requirements for the increase.


As a result of today’s inspection, no deficiencies were noted.



Report reviewed. Copy of report provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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