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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701223
Report Date: 11/15/2023
Date Signed: 01/12/2024 09:42:00 AM

Document Has Been Signed on 01/12/2024 09:42 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ARGONAUT CARE HOME, INC.FACILITY NUMBER:
032701223
ADMINISTRATOR:NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:860 ARGONAUT DR.TELEPHONE:
(209) 217-1512
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 4DATE:
11/15/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff on dutyTIME COMPLETED:
04:45 PM
NARRATIVE
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On 11/15/23, 10am, Licensing Program Analysts (LPAs) Christina Valero and Arvin Villanueva arrived at this facility to conduct a post-licensing inspection. LPAs met with staff on duty (S1), Shyniel Brown and explained the purpose of the visit. S1 then informed Chukwudi Ikiseh via telephone. Chukwudi is unable to come to the facility during the visit and gave S1 permission to sign this report. During this visit, one staff was on duty with four residents in care.

At 10:30am LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, other common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a single-story home with a fire clearance to serve 6 non-ambulatory elderly residents and hospice approved for two (2). Facility has 4 resident bedrooms, and 2 bathrooms for resident use. Each resident have their own bedroom. LPAs observed both bathrooms to contain grab bars, non-skid flooring, shower chairs, close lid trash containers and hygiene supplies. Resident bedrooms were sanitary, furnished, well-lit and had adequate storage for resident’s belongings.

The facility common areas are cleaned and furnished. Facility has a dining area off the kitchen and a formal living room. In the kitchen area, LPAs observed the kitchen to be sanitary and free of clutter. Additionally, the kitchen knives and other sharp objects are kept in a locked drawer. Toxins and cleaning supplies are kept locked. LPAs observed the facility to have adequate food supply with at least 2 days’ worth of perishables and 7 days’ worth of non-perishables. LPAs observed the garage to be free of clutter. The garage also houses additional fridge and additional non-perishable food. Additionally, the garage was observed to have couches.

{Con't on 809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARGONAUT CARE HOME, INC.
FACILITY NUMBER: 032701223
VISIT DATE: 11/15/2023
NARRATIVE
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{Con't from 809}

The front yard and the backyard are observed to be free of obstruction and well-maintained. Additionally, the backyard has a covered pool but does not contain water. The backyard is furnished with outdoor furniture for outdoor activities. Water temperature reads 105*F to 120*F in one of the bathrooms and room temperature reads 74*F. Smoke and carbon detectors were in good repair. Fire extinguisher was serviced on 5/19/23. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 4 resident files were reviewed for regulatory compliance. Only 1 staffing file were available for review for regulatory compliance during this visit. Evidence of staff training was not available for review during this visit. Additionally, evidence of staff first aid training and certificate was not available for review during this visit. Administrator's files were not available for review to confirm appropriate training were taken. In 2 of the 4 resident files that were reviewed, physician reports needed to be updated. During resident file review, LPAs observed 1 of the 4 residents is bedridden and has a restricted health condition. LPAs completed 2 resident interviews and 1 staff interview. Facility has appropriate internet access available for resident use. During this visit, LPAs did not observe recreational activities being provided to resident. LPAs reviewed facility’s disaster plan to ensure regulatory compliance. During record reviews, evidence of quarterly fire drills were not available for review.

LPAs also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. LPAs requested an updated copy of Liability Insurance, LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Licensee was made aware that an immediate civil penalty of $500 will be assessed during today's visit. Interview was held with the Chukwudi Ikiseh via telephone and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(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 interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff (available for review during the visit) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee to submit updated first aid and CPR certificate for all staff associated to this facility to the Department by the POC due date.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff (available for review during the visit) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee to submit updated first aid and CPR certificate for all staff associated to this facility to the Department by the POC due date.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPAs observed no evidence of fire drills during this visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee to submit evidence of quarterly fire drills to the Department by the POC due date.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 residents in care was observed to be in bedridden status and facility is not licensed to have a bedridden residents and does not have an appropriate fire clearance for bedridden residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee to submit a plan to be in compliance of CCR 87606(c). Failure to correct deficiency will result in daily civil penalties in the amount of $100 per violation each day.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)(3)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as the current designated person on record is no longer employed at this facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee to submit updated LIC 308 to the Department by the POC due date.

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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview and record review the licensee did not comply with the section cited above as only one (1) staff file was available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee to ensure all personnel records are updated and maintained in the facility at all times.
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above as no administrator's file was available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee to ensure all personnel records, including administrator's file, are updated and maintained in the facility at all times.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above as only one (1) staff file was available for review and no administrator's file was available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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2
3
4
Licensee to ensure all personnel records, including administrator's file, are updated and maintained in the facility at all times.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above as no evidence of staff training was available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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2
3
4
Licensee to ensure staff trainings are updated and maintained in the facility at all times.
Licensee to ensure staff are trained annually as stated in the above regulation.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/12/2024 09:42 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/15/2023 at 03:06 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: ARGONAUT CARE HOME, INC.

FACILITY NUMBER: 032701223

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPAs did not observed recreational activities being provided to the residents in care during the visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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2
3
4
Licensee to submit activity calendar to the Department by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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