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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:34:57 PM

Document Has Been Signed on 09/25/2024 03:34 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/
DIRECTOR:		NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:10575 RIDGECREST DR.TELEPHONE:
(209) 268-0597
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Shadae James, Designated StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 9/25/24 at 1:55pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit related to recently submitted death report. LPA met with the Designated Staff, Shadae James (S1) and explained the purpose of the visit. Present during today's visit were 3 residents in care with 2 staff (S1 and S2).

LPA reviewed death reports for Resident (R1) and accompanying documentation with S1 and confirmed accuracy of the report. At this time, the facility has not receive a death certificate.

After reviewing the death report with S1, S1 needed to leave the facility for a resident appointment. S2 was the only staff on duty for the rest of the visit.

Death report stated that R1 had passed away as a result of aspiration while eating dinner. Per record review and interview with S1, incident occurred on 9/10/24. The death report was received by the Department on 9/19/24, which is outside the reporting requirement.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

During the exit was interview, LPA reviewed the report and Plan of Correction with S1 over the phone and S2 signed this report, and a copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 09/25/2024 03:34 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 09/25/2024 at 02:28 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87211(a)(1)(A)

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(a) (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events...(A)Death of any resident from any cause regardless of where the death occurred...

This requirement is not met as evidenced by:
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Per discussion with the Designated Staff (S1), licensee to submit a written plan of correction detailing the steps the facility will take to ensure all reportable incidents are reported to the Department in a timely manner. Plan to be submitted by POC due date.
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Based on record review and interview, a death report was submitted to the Department past the seven days requirement, which poses/posed a potential health, safety or personal rights risk 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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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