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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
345002940
Report Date:
10/07/2024
Date Signed:
10/07/2024 01:36:46 PM
Document Has Been Signed on
10/07/2024 01:36 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 II
FACILITY NUMBER:
345002940
ADMINISTRATOR/
DIRECTOR:
DARIUS O. STIR
FACILITY TYPE:
740
ADDRESS:
3120 COLORADO ST.
TELEPHONE:
(916) 757-0918
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
6
CENSUS:
6
DATE:
10/07/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:
Darius Stir
TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction visit regarding the deficiencies cited on 9-19-2024. LPA met with Administrator and explained the purpose of the visit.
Plan of Corrections was originally due Friday 10-3-2024 but has been extended to Wednesday 10-9-2024:
22 CCR 87411 Personnel Requirements
-
Licensee is to conduct an audit of facility roster and associate any additional staff needed to roster. Licensee is to inform LPA Yang of completion.
22 CCR 87211 Reporting Requirements
-
Licensee is to submit a statement of understanding of the reporting requirements of 22 CCR Section 87211.
LPA and Administrator discussed POC cannot be extended any further. Failure to correct will result to $100 per day civil penalty until POC received.
Exit interview and a copy of report was provided.
SUPERVISORS NAME
:
Anthony Perez
LICENSING EVALUATOR NAME
:
Cassie Yang
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/07/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/07/2024
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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