Community Care Licensing

Document Has Been Signed on 10/07/2024 01:35 PM - It Cannot Be Edited

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:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Shavel Williams		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING II	FACILITY NUMBER: 345002940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/09/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Same violation POC is pending which is due on 10-9-2024. Once received, LPA will clear both POC's.
	8 9 10 11 12 13 14	Based on file review, Licensee did not comply as LPA did not receive an incident report for R3 on an incident occuring on 9-16-2024 and receiving an incident report for R1 which occurred approximately three months prior to reporting to CCLD which poses a potential risk for residents in care.	8 9 10 11 12 13 14	Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.
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SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Cassie Yang LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING II	FACILITY NUMBER: 345002940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan of facility procedure for R2's monthly medication to ensure refills are received in a timely manner. POC is due to LPA on 10-8-2024.
	8 9 10 11 12 13 14	Based on file review and interview, Licensee did not comply to the section above as it was observed that R2 was out of three medication refills for approximately a month prior to being sent out to the hospital for new refill orders which poses an immediate risk for residents in care.	8 9 10 11 12 13 14	Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.
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SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Cassie Yang LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024

Link to Parent Document Below:

FACILITY NAME: MADISON SQUARE SENIOR LIVING II	FACILITY NUMBER: 345002940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2024 Section Cited HSC 1569.312(d)	1 2 3 4 5 6 7	§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	- R1 and Conservator consented to Apple AirTag on R1. - Licensee will update R1's LIC 602 with PCP and reassess R1's needs and service plan to ensure R1 gets the care and supervision needed. -Provide LPA of appointment date by POC due date
	8 9 10 11 12 13 14	Based on file review, Licensee did not comply with the section cited above as R1 was reported to AWOL twice within this year which LIC602 stated R1 cannot leave facility unassisted, which poses an immediate risk for residents in care.	8 9 10 11 12 13 14	Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.
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SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Cassie Yang LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024