Inspection Reports for Madison Square Senior Living
4517 Cyclamen Way, Sacramento, CA 95841, CA, 95841
Back to Facility ProfileInspection Report Summary
Most inspections at this facility found no deficiencies, with several reports showing full compliance and proper safety measures. However, some inspections identified issues primarily related to resident care documentation, staff training, and room assignments for non-ambulatory residents. The most serious events occurred in early 2025, including immediate risk citations for inadequate supervision, lack of a proper signal system, and a $500 fine following a resident’s fall and death. The latest report from October 22, 2025, noted a deficiency for building alterations made without a required permit, which posed a potential risk but was less severe than earlier findings. Several complaint investigations were unsubstantiated, and while some issues persist, recent reports suggest some improvement in compliance over time.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 1
Oct 22, 2025
Visit Reason
A case management visit was conducted to review facility compliance, discuss outstanding issues including building alterations without permits, administrator hiring status, and annual fee payments.
Findings
A deficiency was noted due to alterations made without a required building permit. Other issues discussed included maintaining and updating care plans and training for resident conditions.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met based on statements and records. This posed a potential risk. | Type B |
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Nov 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Maribeth Senty | Licensing Program Manager | Conducted the case management visit and named in the report |
| Darius Stir | Met with during the visit | |
| Samantha Shaw | Administrator/Director | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 1
Sep 16, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure compliance with health, safety, and licensing regulations at Madison Square Senior Living Facility.
Findings
The inspection found no immediate health, safety, or personal rights violations during the facility tour. However, deficiencies were cited related to resident participation in decision-making, specifically the failure to update reappraisals/service plans within 12 months for 3 of 4 residents reviewed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with resident participation in decision-making requirements; 3 of 4 residents did not have reappraisals/service plans updated within 12 months. | Type B |
Report Facts
Residents reviewed: 4
Staff files reviewed: 2
Deficiencies cited: 1
Plan of Correction due date: Oct 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Samantha Shaw | Facility staff met with during inspection and exit interview | |
| Darius Stir | Administrator | Facility Administrator who assisted during inspection |
Inspection Report
Follow-Up
Census: 4
Capacity: 6
Deficiencies: 2
Apr 1, 2025
Visit Reason
The visit was conducted as a follow-up on the March 27, 2025 visit to investigate an incident involving resident R1's fall with injury requiring hospitalization and subsequent death.
Findings
The investigation found deficiencies including lack of adequate supervision for R1, failure to meet prescribed care needs, medication administration errors, and absence of a signal system for resident assistance. Two Type A deficiencies were cited posing immediate health and safety risks, and a $500 civil penalty was assessed.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure at least one night staff person awake and on duty for residents with dementia, posing an immediate risk to R1. | Type A |
| Failure to have a signal system meeting regulatory criteria for facilities with separate floors, posing an immediate risk to residents. | Type A |
Report Facts
Civil penalty amount: 500
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Darius Stir | Administrator | Named in relation to findings of failure to fulfill duties regarding resident care and supervision. |
Inspection Report
Census: 4
Capacity: 6
Deficiencies: 0
Mar 27, 2025
Visit Reason
The inspection was conducted as a case management visit following receipt of an incident report regarding a resident's fall with injury requiring hospitalization and subsequent death.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed records and requested additional documentation to be submitted by a specified date.
Report Facts
Capacity: 6
Census: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management inspection and reviewed records |
| Darius Stir | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 4
Capacity: 6
Deficiencies: 0
Dec 30, 2024
Visit Reason
The inspection was conducted as a case management visit to review the facility's process of increasing non-ambulatory capacity for an additional room that was previously ambulatory only.
Findings
The Licensing Program Analyst inspected the home to ensure ambulatory occupancy in the room under review and confirmed that fire safety measures are in place. The licensee is still completing Fire Marshal requirements for the increase. No deficiencies were noted during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and met with the Administrator. |
| Shavel Williams | Administrator | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Census: 4
Capacity: 6
Deficiencies: 0
Nov 26, 2024
Visit Reason
An in-office non-compliance conference was held to discuss recent compliance history and develop a non-compliance plan with the licensee.
Findings
A non-compliance plan was developed and agreed upon by the licensee. No new citations were issued as a result of the meeting.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Representing licensee Madison Square Senior Living LLC during the non-compliance conference. |
Inspection Report
Plan of Correction
Census: 5
Capacity: 6
Deficiencies: 1
Oct 31, 2024
Visit Reason
The visit was conducted as a Plan of Correction (POC) follow-up to verify compliance with previously issued citations related to medical assessments.
Findings
The facility had not completed updated LIC 602 forms for identified residents nor scheduled appointments for physical assessments as required. No additional deficiencies were noted during this visit, but civil penalties continue to accrue due to failure to correct prior citations.
Deficiencies (1)
| Description |
|---|
| Two residents' LIC602 medical assessments were incomplete and conducted remotely by a physician assistant instead of a physician, failing to meet physical assessment requirements. |
Report Facts
Civil penalty accrual rate: 100
Facility capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Darius Stir | Administrator | Facility administrator contacted regarding the visit and findings. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Oct 9, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to ensure compliance with Title 22 regulations for the care home.
Findings
The facility was generally compliant with regulations, including proper furnishing, sanitation, food storage, and safety measures. However, one deficiency was cited related to medical assessments where physical examinations were not conducted for 2 of 5 resident files reviewed.
Deficiencies (1)
| Description |
|---|
| Failure to conduct physical examinations for 2 out of 5 resident files as required by CCR 87458(b)(1), posing potential health, safety, or personal rights risks. |
Report Facts
Deficiencies cited: 1
Residents files reviewed: 5
Staff files reviewed: 1
Food supply: 2
Food supply: 7
Hot water temperature: 106.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Met with Licensing Program Analyst during the inspection. |
| Angela Hood | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 0
Nov 30, 2023
Visit Reason
The visit was an unannounced office meeting conducted remotely to discuss recent compliance issues and review plans of correction from prior visits dated 10/31/23 and 11/17/23.
Findings
The licensee is currently in compliance with regulatory requirements, and no deficiencies were cited during this meeting. Technical Support Program consultation was offered and accepted to assist with medication administration and other issues.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Met with during the remote office meeting and discussed compliance issues. |
| Maribeth Senty | Licensing Program Manager | Conducted the remote office meeting and reviewed citations and advisories. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the remote office meeting and reviewed citations and advisories. |
Inspection Report
Plan of Correction
Census: 5
Capacity: 6
Deficiencies: 0
Nov 28, 2023
Visit Reason
The inspection visit was conducted as a Plan of Correction (POC) inspection to verify correction of deficiencies issued on 10/31/2023 related to incomplete resident and staff files.
Findings
The Licensing Program Analyst reviewed 4 resident files and 2 staff files and found all files complete for required documents. No deficiencies were cited as a result of this visit, and the plans of correction were cleared.
Report Facts
Resident files reviewed: 4
Staff files reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Darius Stir | Administrator | Facility administrator who assisted with the visit |
Inspection Report
Plan of Correction
Census: 4
Capacity: 6
Deficiencies: 2
Nov 17, 2023
Visit Reason
The inspection visit was conducted as a Plan of Correction (POC) inspection for deficiencies issued on 10/31/2023, to verify correction of cited deficiencies including fire clearance and criminal record clearance violations.
Findings
Clearance issues for staff have been resolved, but one resident (R2) continues to reside in a room cleared only for ambulatory residents, posing an immediate risk. Annual fees remain unpaid, resulting in a citation. The administrator is still correcting resident and staff file issues with a plan of correction due by 11/21/2023.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident R2, who is non-ambulatory, resides in a room cleared only for ambulatory residents, posing an immediate health, safety, or personal rights risk. | Type A |
| Licensing fees have not been paid as required by Health and Safety Code section 1569.185. | Type B |
Report Facts
Deficiencies cited: 2
Plan of Correction due dates: Type A deficiency due 11/18/2023; Type B deficiency due 11/20/2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Plan of Correction inspection and authored the report. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager and Supervisor in the report. |
| Darius Stir | Administrator | Facility Administrator involved in the inspection and correction process. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 6
Oct 31, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure compliance with health and safety regulations using the CARE inspection tool.
Findings
The inspection found multiple deficiencies including a non-ambulatory resident residing in an ambulatory-only room, incomplete resident and medication files, incomplete staff files lacking required criminal record clearances, and staff not having completed required training. Plans of correction were established with due dates.
Severity Breakdown
Type A: 2
Type B: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Non-ambulatory resident residing in a room cleared for ambulatory only, posing immediate health and safety risk. | Type A |
| Two staff members (S1 and S2) did not have required criminal record clearance prior to working in the facility, posing immediate health and safety risk. | Type A |
| Personnel records for 2 of 2 staff were incomplete, posing potential health, safety or personal rights risk. | Type B |
| Staff training requirements not met for 2 of 2 staff, posing potential health, safety or personal rights risk. | Type B |
| Resident records incomplete for 4 of 4 files reviewed, posing potential health, safety or personal rights risk. | Type B |
| Medication dosage records not maintained as required in 4 of 4 client files reviewed, posing potential health, safety or personal rights risk. | Type B |
Report Facts
Residents present: 4
Total licensed capacity: 6
Staff files incomplete: 2
Resident files incomplete: 4
Staff lacking criminal clearance: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and signed the report |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
| Darius Stir | Administrator | Facility administrator notified and assisted during inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 12, 2022
Visit Reason
The visit was an unannounced required Annual Inspection conducted by the Licensing Program Analyst to assess compliance with regulations and facility conditions.
Findings
The facility was found to be in good repair with no citations issued. All required safety, health, and emergency equipment were present and functioning properly. The facility had no COVID-19 cases to date and infection control protocols were followed with no issues.
Report Facts
Facility capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Post Licensing
Census: 6
Capacity: 6
Deficiencies: 0
Oct 14, 2021
Visit Reason
The visit was conducted as an annual required and post licensing inspection of the Madison Square Senior Living Facility.
Findings
No deficiencies were cited during the post licensing visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Met with Licensing Program Analysts during the inspection visit. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 14, 2021
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection focusing on the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Stir | Administrator | Met with Licensing Program Analysts during the inspection and involved in infection control domain completion. |
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