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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:45:06 PM

Document Has Been Signed on 12/06/2023 04:45 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: 4DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Darius StirTIME COMPLETED:
04:50 PM
NARRATIVE
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On 12/6/2023 at approximately 1PM, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required 1-year annual inspection utilizing the CARE inspection tool. At time of arrival, LPA observed the presence of Metro Fire arrival. LPA met with Caregiver and Administrator at the door, and explained the purpose of the visit. Today's census is four with one resident on hospice services.

Time of visit, LPA observed R1 to be transported to hospital for evaluation. LPA reminded Administrator to submit LIC 624 regarding R1's hospital transportation. LPA and Administrator conducted a tour of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (4) resident bedrooms, (2) bathroom, kitchen, laundry room and staff office/room. In the areas toured the following issued were observed: LPA observed the CCLD compliance poster (PUB 475) to be missing. LPA observed fire door to be opened using a door stopper. LPA observed fire extinguisher to be in need of service as last inspection was 10/17/2022. LPA observed sharps to be stored in an unsecured drawer. LPA observed R2 and R3 to be non-ambulatory based on file review and observed R2 and R3 to be residing in an ambulatory only room.

LPA conducted a resident file review. LPA observed 4 of 4 files are incomplete for various required forms. Administrator stated he is in the process of completing all documents based on LIC 311F checklist.

LPA conducted a personnel file review. LPA observed 1 of 2 files are incomplete for forms and training. LPA observed S2 to not have a personnel file. LPA observed no proof of CPR and First Aid training present on file. LPA observed S1 to be working at the facility which she "arrived five days ago" without any fingerprint clearance. LPA informed Administrator staff cannot work at the facility until the individual is fingerprinted and cleared.

Please continue on LIC 809-C...
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 345002940
VISIT DATE: 12/06/2023
NARRATIVE
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LIC 809-C...

LPA provided LIC 9182 to Administrator for clearance transfer as LPA observed facility to have only S2 associated to the facility. LPA provided LIC 311F to Administrator for file completion.

LPA is requesting liability insurance to be provided to LPA Yang via email by Friday December 8, 2023.

LPA and Administrator discussed submitting a new LIC 200 and facility sketch to LPA for a new fire inspection for 5 non-ambulatory and 1 ambulatory.

As a result of this inspection, the following deficiencies were cited on LIC 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Exit interview conducted with Administrator. Signature confirming documents were received was conducted with Caregiver who entered the facility shortly before exit interview. LPA received physical copy of LIC 9182 for S3. Report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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Document Has Been Signed on 12/06/2023 04:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/06/2023 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON SQUARE SENIOR LIVING II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA and Administartor observed two kitchen knives to be stored in an unsecured drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Knives were retrieved and locked immediately.
Licensee will submit a statement of compliance that all dangerous items will be stored immediately after usage. Statement is due to LPA Yang by 5PM December 7, 2023.
Type A
Section Cited
CCR
87202(a)(1)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the licensee did not comply with the section cited above in 2 out of 4 non-ambulatory residents are residing in an ambualtory only room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Administrator will assist in relocating R2 and R3 to non-ambulatory approved rooms in the facility.
This matter will be discussed with management for additional assistance if R2 and R3 are not willing to relocate to shared bedrooms.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


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Document Has Been Signed on 12/06/2023 04:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/06/2023 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON SQUARE SENIOR LIVING II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
1569.618
Administration and management of residential care facilities; substituted qualifications; employee scheduling
Date Composed: 07/15/2010 Effective Date:


§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed no first aid training and no CPR training on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Administrator will submit a compliance statement to LPA Yang by 5PM, December 7, 2023.
Proof of CPR and First Aid certification is to be submitted to LPA Yang by Friday December 22, 2023.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


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Document Has Been Signed on 12/06/2023 04:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/06/2023 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON SQUARE SENIOR LIVING II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(b)(1)(B)
§1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances
(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons:
(1) (B) Any person, other than a client, residing in the facility. Residents of unlicensed independent senior housing facilities that are located in contiguous buildings on the same property as a residential care facility for the elderly shall be exempt from these requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as LPA observed 1 of 2 staff working at the facility without a criminial record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Licensee will submit proof that S1 have moved from the home untill criminal record clearance is received.
Licensee will also submit a LIC 500 to confirm adequate staffing, submit the following to LPA Yang by 5PM, December 7, 2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


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Document Has Been Signed on 12/06/2023 04:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/06/2023 at 04:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON SQUARE SENIOR LIVING II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed 4 of 4 resident files to be incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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LIC 311F was previously provided. POC visit will be conducted to confirm completion.
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed no LIC 503 present for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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POC visit will be conducted to confirm completion.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/06/2023 04:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/06/2023 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON SQUARE SENIOR LIVING II
FACILITY NUMBER: 345002940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
87468 Personal Rights
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.
(2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:
(A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed PUB 475 to be missing from facility which was discussed during pre-licensing inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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POC visit will be conducted to observe proof of correction.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


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