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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701223
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:41:54 PM

Document Has Been Signed on 03/07/2024 03:41 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 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: 3DATE:
03/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff on dutyTIME COMPLETED:
03:45 PM
NARRATIVE
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On 3/7/24 at 10:30am, Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility to conduct an unannounced Plan of Correction (POC) visit. LPA initially met with the staff on duty and explained the purpose of the visit. Chukwudi Isikeh, administrator, was notified of the visit by the staff. Staff on duty was given permission to sign this report. The purpose of this visit was to verify the plan of correction that was required to be completed on ____ for deficiencies that were previously cited on a prior visit conducted on 11/27/2023. Present during this visit are 3 residents in care with 1 staff on duty.

During this visit, LPA attempted to conduct file reviews of the 4 staff noted on the LIC 500 dated 11/25/23. Staff on duty was only able to retrieve 2 staff files for review at this time. Per staff on duty, the files for the administrators are not present at this facility. Additionally, per interview of staff on duty, staff_1 (S1)noted on the LIC 500 dated 11/25/23 is no longer employed at this facility. LPA also requested S1's files for review but staff on duty is unable to retrieve and stated it is not at this facility at this time.

LPA also reviewed resident files and found that resident_1(R1) is using a catheter. Per interview with R1 and staff on duty, it was revealed that R1 is unable to care for their catheter and requires staff assistance at this time. Per interview with Chukwudi Isikeh, a request for an exception for R1's catheter has not been submitted to the Department for approval. Further resident file review revealed that R1 does not have Needs and Services Plan (LIC 625) in their file.

LPA requested from the facility to submit an updated LIC 500 to the Department.

Con't to LIC 809-C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 5
Document Has Been Signed on 03/07/2024 03:41 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/07/2024 at 02:19 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions: (a) ... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
This is not met as evidenced by:
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Licensee to submit a statement of understanding of the regulation related to restricted/prohibited health conditions to the Department by the POC due date.
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Based on interviews and record review the Licensee did not ensure that a written request for an exception was sent to the Department for approval as soon as R1 started using a catheter. This poses an immediate, health, safety, and personal rights risks to persons in care.
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Licensee to submit an exception request, including necessary documents, to the Department for approval. LPA will email licensee what documents are needed.
Type B
03/13/2024
Section Cited
CCR87405(d)(2)

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(d) The administrator shall have...
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This is not met as evidenced by:
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The licensee shall provide a statement of understanding regarding the following regulation 87405(d)(2) to the Department by the POC date.
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 Based on interviews and record review, the licensee did not ensure that the facility obtained an exception request for R1's indwelling catheter as soon as R1 started using catheter. This poses a potential, health, safety, and personal rights risks to persons in care.
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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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2024 03:41 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/07/2024 at 02:46 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
87412(g)

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(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
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Licensee to ensure personnel records, including administrators files, are available for review at any time.
Licensee to ensure personnel records, including administrators files, are complete as per regulation.
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Based on interview and record review, licensee did not comply with the section cited above as the files for the administrators were not available for review during this visit.
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Licensee also agrees to read and write a statement of acknowledgment that licensee have read the regulations being cited and have understood the regulation. The written statement is to be submitted to the Department by the POC due date.
Type B
03/14/2024
Section Cited
CCR87412(h)

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(h) All personnel records shall be retained for at least three (3) years following termination of employment.

This requirement is not met as evidenced by:
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Licensee to read and write a statement of acknowledgment that licensee have read the regulations being cited and have understood the regulation. The written statement is to be submitted to the Department by the POC due date.
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Based on interview, licensee did not comply with the section cited above as the file for S1 who is no longer employed at this facility is present at this facility and not available for review during this visit. This poses a potential, health, safety, and personal rights risks to persons in care.
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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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 03/07/2024
NARRATIVE
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...Con't from LIC 809

Based upon this inspection, LPA Villanueva observed the following:
  • The deficiency cited under Health and Safety Code 1569.618(c)(3) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87411(c)(1) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Health and Safety Code 1569.695(c) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87606(c) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Health and Safety Code 1569.618(b)(3) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(g) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(a)(6)(A) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(a)(12) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Health and Safety Code 1569.625(b)(2) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Health and Safety Code 87219(a)(1) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

Immediate civil penalties are being assessed due to repeat violations. The facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.


As a result of this case management, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted with Shyniel Brown, staff on duty, and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided to the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/07/2024 03:41 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/07/2024 at 03:31 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Licensee to complete R1's Needs and Services Plan and submit the completed form to the Department by the POC due date.
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Base on record review, the licensee did not comply with the section cited above during resident record review, R1 did not have their Needs and Services Plan (LIC625) on file available for review. This poses a potential, health, safety, and personal rights risks to persons in care.
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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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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