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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701223
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:22:19 PM

Document Has Been Signed on 06/12/2024 04:22 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/
DIRECTOR:		NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:860 ARGONAUT DR.TELEPHONE:
(209) 217-1512
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 3DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Chukwudi (Patrick) IkisehTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 06/12/24, 10am, Licensing Program Analysts (LPAs) Ariel Pascua and Arvin Villanueva arrived unannounced at this facility to conduct the required annual inspection. LPAs met with staff on duty (S1), and explained the purpose of the visit. S1 informed Chukwudi (Patrick) Ikiseh via telephone. Patrick arrived at 2pm. During this visit, one staff was on duty with 3 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 one bathroom and contain grab bars, non-skid flooring, shower chairs, close lid trash containers and hygiene supplies. During an inspection of one of the bathrooms, LPAs found a drain cleaner under the sink and was observed to be accessible to residents in care. Resident bedrooms were observed to be furnished, well-lit and had adequate storage for resident’s belongings.

Facility has a dining area off the kitchen and a formal living room. During an inspection of the kitchen area, LPAs observed the knife/sharp drawer was unlocked and accessible to residents in care. In the kitchen refrigerator, LPAs observed a two containers of Lozenges. Per interview with S1, no one is using these Lozenges and S1 threw them in the garbage. 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 contain additional food supplies. Also in the garage LPAs observed resident medications inside a small refrigerator. The small refrigerator was observed to be unlocked. Also the door to the garage was unlocked during this visit which makes it accessible to residents in care. Additionally, the garage was observed to have 2 futons, a cabinet, a drawer, a desk and chairs.

{Con't to 809-C...}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 7
Document Has Been Signed on 06/12/2024 04:22 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/12/2024 at 02:06 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed the deck floor to be in disrepair and the rail of the deck was found to be loose which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Licensee to submit a plan for the repair of the deck and the rail and submit to the Department by the POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed a drain cleaner under the bathroon sink and was observed to be accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Licensee to submit a statement of understanding of the regualtion cited above and submit 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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/12/2024 04:22 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/12/2024 at 02:06 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above. 1 of 4 residents was placed in a bedroom that was not fire cleared for bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Licensee to submit a statement of understading of the regulation cited above to the Department by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/12/2024 04:22 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/12/2024 at 02:06 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 4 of 4 residents do not have PRN Authorization letter signed by their physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee to submit a statement of understading of the regulation cited above to the Department by the POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 1 of 4 residents do not have updated LIC602 and 2 of 4 residents do not have updated Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee to submit a statement of understading of the regulation cited above 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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
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: 06/12/2024
NARRATIVE
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The front yard and the backyard were inspected. Facility has a covered pool but does not contain water. The gate to the pool was observed to be locked and not accessible to residents in care. The backyard is furnished with outdoor furniture for outdoor activities. The deck floor was observed to be in disrepair. The rail for the deck was observed to be slightly bent and loose.

Water temperature read 110 degrees F in one of the bathrooms and room temperature reads 76 degrees F. Smoke and carbon detectors were in tested and operational. Fire extinguisher was last serviced on 5/19/23. Medication storage area was observed to be locked and inaccessible to residents in care (except for the medications found in the garage). First aid kit was observed to have adequate supplies and accessible to staff.

During staff record review, 3 of 5 staff did not have file available for review. The facility administrator, Mama Ngaima does have a current administrator certificate during this visit. Administrator's training requirements were not available for review at this time.

During resident record review, 1 of 4 residents does not have an updated Physicians Report. Last Physician Report was last done on 4/22/2019. 2 of 4 residents in care does not have updated Needs and Services Plan. 1 out of 4 residents were diagnosed as bedridden observed on their 602 however was placed in a non-ambulatory room. 4 of 4 residents do not have PRN Authorization letter.

Facility has appropriate internet access available for resident use. During this visit, LPAs did not observe recreational activities being provided to resident. During record reviews, evidence of quarterly fire drills were observed.

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 to be email to LPA Villanueva.

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 Patrick Ikiseh and a copy of this report and appeal rights were provided.

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

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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