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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 12/28/2023
Date Signed: 02/07/2024 10:48:31 AM

Document Has Been Signed on 02/07/2024 10:48 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 3FACILITY NUMBER:
032701225
ADMINISTRATOR:NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:10575 RIDGECREST DR.TELEPHONE:
(209) 268-0597
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 3DATE:
12/28/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff on dutyTIME COMPLETED:
03:00 PM
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On 12/28/23 at 9:45am Licensing Program Analysts (LPAs) Christina Valerio and Arvin Villanueva conducted an unannounced post licensing visit, with the use of the CARE Inspection Tool. LPA initially met with the staff on duty and explained the purpose of today’s visit. The administrator was informed of the visit. The facility is currently licensed to serve 6 non-ambulatory elderly residents, of which 1 may be bedridden. Room #3 from the facility sketch is cleared for 1 bedridden resident. The facility is approved for 2 hospice residents. Currently, the facility has no hospice and/or bedridden residents in care. Present during this visit were 3 residents in care with 1 staff on duty. Also present during this visits were outside agency nurses/professionals.

At 10am LPAs inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There is a swimming pool on the premises located in the backyard that is fenced, locked, and inaccessible to residents in care. Outside of the facility was observed to be clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and area with outdoor umbrella for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed 3 resident bedrooms and 2 bathrooms for resident use. Resident bathrooms were operational and adequately supplied including with grab bars and non-skid flooring. A third bathroom is observed to be for employee used only. LPAs observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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 3
FACILITY NUMBER: 032701225
VISIT DATE: 12/28/2023
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{Con't from LIC809}

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 74 degrees F. Water temperature in one of the bathroom was measured at 116 degrees F. Fire extinguisher was serviced on 5/21/23. Smoke detectors and carbon monoxide were tested and found to be operable during this visit.

Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed complaint information posted. Facility has appropriate internet access available for resident use. LPA observe facility’s equipment and supplies to meet activity program needs of residents in care.

During this inspection, LPAs conducted an audit of facility files, 3 of 3 resident files, and 1 staff file for regulatory compliance. During this visit, only 1 staff file was available for review. The facility is current on annual license fees. Updated facility LIC500 was not available for review during this visit. LPAs attempted 2 resident interviews and 1 staff interview. LPAs could not confirm if facility conducts quarterly fire/disaster drills as there is no records of drills available during this visit.

Due to technical issues, LPA will return at another date until the issue can be resolved to continue with the post-licensing visit.

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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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