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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:15:50 PM

Document Has Been Signed on 02/13/2024 12:15 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: 3DATE:
02/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Shadae JamesTIME COMPLETED:
12:15 PM
NARRATIVE
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On 2/13/2024 at 10:08am 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 and issue additional deficiencies from the continuation visit on 2/7/24. LPA initially met with the staff on duty and explained the purpose of today’s visit. The facility supervisor, Shadae James was informed of the visit and arrived shortly after. Present during this visit were 2 residents in care with 1 staff on duty.

During this visit, LPA issued the remaining deficiencies cited from the case management annual continuation visit on 2/7/24. Also during this visit, LPA provided technical assistance to the facility supervisor on maintaining personnel records in the facility and making sure records are available for review by the Department any time.

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 Shadea and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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Document Has Been Signed on 02/13/2024 12:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/13/2024 at 11:21 AM
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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records: (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. 4 of 4 staff files were reviewed and found files to be incomplete and 1 of 4 files was not available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee to enusre to keep staff files at the facility available for review at all times.
LIcensee agreed to create checklist of what to keep in the staff files according to the regulation and submit the checklist to the Department by POC due date.
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions: (1)...training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. 4 of 4 staff files reviewed were missing this requirement and at least 2 staff files were not available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee to ensure the required intial trainings are provided to staff within the first four weeks of employment.
Licensee agreed to create a checklist of initial trainings to provide to staff and submit the checklist 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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 12:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/13/2024 at 11:33 AM
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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. 4 of 4 staff files reviewed, there was no evidence of medication training, including hands-on shadowing, was provided to staff prior to staff assisting residents in care with their medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee to ensure staff assisting residents in care with their medications recieve necessary trainings per regulation prior to staff assisting with medication administration. Licensee to submit a declaration of understanding of the regulatory requirments for assisting with resident's medication. Submission to the Department is by the POC due date. Licensee to provide staff training on medication assistance as required by regulations. Submit proof of training by POC due date.
Type B
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 record review, the licensee did not comply with the section cited above. Documentation of quarterly emergency/fire drills was not available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee to ensure to conduct emergency/fire drills on a quarterly basis and document each drill per regulation.
Licensee agreed to submit to the Department proof of emergency/fire drills by 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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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