<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:59:42 PM

Document Has Been Signed on 12/19/2024 01:59 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/
DIRECTOR:		DARIUS O. STIRFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 757-0918
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Darius StirTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/19/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a quarterly case management visit as agreed during Non-Compliance Conference held on November 26, 2024. LPA met with Administrator and explained the purpose of the visit.

During today's visit, LPA conducted a file audit to ensure files are complete.

LPA observed presence of home health and hospice correspondence between agency and facility for R1, R2 and R3. LPA conducted a file review for personnel and resident records. LPA observed the required documents present and completed for residents in care.

No deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1