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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 02/07/2024
Date Signed: 02/07/2024 04:07:13 PM

Document Has Been Signed on 02/07/2024 04:07 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 3FACILITY NUMBER:
032701225
ADMINISTRATOR:NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:10575 RIDGECREST DR.TELEPHONE:
(209) 268-0597
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 2DATE:
02/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Paulette Cameron, Staff on dutyTIME COMPLETED:
04:15 PM
NARRATIVE
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On 2/7/2024 at 10:15am Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management continuation visit to continue the post licensing initiated on 12/28/2023. LPA initially met with the staff on duty and explained the purpose of today’s visit. The facility supervisor was informed of the visit. Present during this visit were 2 residents in care with 1 staff on duty. From last visit, LPA was having technical issues with the CARE Tool. During this visit, the CARE Tool is still not accessible for utilization.

During this visit, LPA conducted facility observation, resident file reviews, medication reviews, staff file reviews and facility file reviews. During the facility observation, LPA observed residents in care watching TV throughout the visit. Staff on duty interacted with residents every now and then. No other activities were offered to residents. Water temperature in 1 of 3 bathrooms was measured at 117 degrees F. Room temperature during this visit was measured at 71 degrees F. Facility have adequate food supplies with 2-day perishables and 7-day non-perishables were maintained for 2 residents. Overall, the facility was observed to be cleaned and free of obstructions. During the observation of the kitchen refrigerator, LPA observed an insulin injection pen stored in the refrigerator. LPA did not observe a thermometer in the refrigerator and unable to determine the temperature. Thermometer reading in the freezer was observed to be at 0 degree F.

During staff file review, LPA observed 3 of 3 staff files that were available for review were observed to be incomplete. Additionally, 1 of 3 staff files are not available for review during this visit. Administrator's files are also not available for review at this time. Per staff, the files are not in the facility upon request.

{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)
Page: 1 of 6
Document Has Been Signed on 02/07/2024 04:07 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/07/2024 at 02:25 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 3
FACILITY NUMBER: 032701225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above where during facility observation, LPA observed an insulin injection pen stored inside the kitchen refridgerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee to schedule additional medication training with all staff who handle medications covering the regulation cited above. Licensee to submit training date to the Department by the POC due date and once training complete, Administrator to submit signed staff training.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 where during medication review, 2 of R1's medications were found to not have physician's order available for review during this visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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A statement of correction will be completed and submitted to the Department by the POC due date. Licensee to obtain physician's orders of all residents' medications and submit physician's order to the Department once obtained.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/07/2024 04:07 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/07/2024 at 03:04 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 3
FACILITY NUMBER: 032701225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above where during medication review of resident_1 (R1), LPA observed 5 medications to be missing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee to obtain all missing medications for R1. Licensee to send in a copy of the centrally stored medication record, indicating missing medications are available for R1. POC due date.
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services: (5)... staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

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 where during a review of the medication administration record (MAR) for Febuary 2024, LPA observed 4 of R1's medications to have missing staff initials since 2/1/2024, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee to schedule additional medication training with all staff who handle medications covering following MD orders, refills and documentation. Licensee to submit the date of the training to the Department by POC due date; and once training is completed, licensee to submit the signed training to the Department.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/07/2024 04:07 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/07/2024 at 03:39 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 3
FACILITY NUMBER: 032701225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services: (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above where during resident file review, 2 of 2 resident files did not contain PRN authorization signed by physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee to obtain PRN authorization letter from residents' physician and submit the signed PRN authorization 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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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: 02/07/2024
NARRATIVE
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{Con't from LIC809}

During resident file reviews, 2 of 2 resident files available for review were observed to be incomplete. 1 of 2 resident files were observed to be missing the needs and services plan. 2 of 2 resident files were observed to have missing PRN Authorization signed by their physicians. During medication review, LPA observed the following: some medications are expired, some medications were not recorded in the centrally stored medication form (LIC622), some medications do not have physician's order available for review, some prescribed medications are not available for review. Per review of the facility's medication administration record (MAR), 4 medications were observed to be missing staff initials since 2/1/2024.

Due to insufficient time, this post-licensing will require a continuation visit. The Department will return at a later date to complete the issuance of additional deficiencies.

Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Failure to correct deficiencies may result in civil penalties. Interview was held with the the staff on duty and a copy of this report and appeal rights were provided.

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)
Page: 5 of 6
Document Has Been Signed on 02/07/2024 04:07 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/07/2024 at 03:46 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 3
FACILITY NUMBER: 032701225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(i)
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above where during a medication review, LPA observed 2 of R1's medications to be expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee tol conduct a medication audit on medications. Licensee to ensure that all staff responsible for administration of medication are re-trained on facility protocol/procedure as it relates to destruction of expired/discontinued medications a timely manner. Licensee to submit the staff training date by POC due date and once training is complete, licensee to submit the proof of training to the Department.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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