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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 06/24/2025
Date Signed: 06/24/2025 04:19:54 PM

Document Has Been Signed on 06/24/2025 04:19 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: 4DATE:
06/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Pualette Cameron, Staff on dutyTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 6/24/2025, at 2pm Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their required annual inspection visit. LPA initially met with the staff on duty Paulette Cameron (S1) and stated the purpose of this visit. The facility supervisor Renae Earl (S2) was notified and arrived shortly after. The Licensee Chukwudi (Patrick) Ikiseh was notified of the visit.
Present during this visit were 4 residents in care with one staff on duty.
Upon arrival, LPA observed 2 residents in the living room sitting on the sofa watching TV. Two other residents were in their bedrooms.

LPA evaluated the physical plant with S2 to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected including but not limited to the kitchen, 3 resident bedrooms, 3 resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clear of obstructions at this time. LPA inspected 3 of 3 resident bedrooms. LPA did not inspect staff room during this visit. LPA measured the hot water temperature in 1 resident bathroom located in the master bedroom and was at 110 degrees Fahrenheit. Room temperature upon arrival was observed at 77 degrees Fahrenheit. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fireplace was observed to be screened.
Inspection of the kitchen, LPA observed 2 scissors inside one of the kitchen drawer. S1 immediately placed them in a locked drawer. Also, in one of the kitchen cabinet, LPA observed cleaning supplies that were not locked. Inside the kitchen refrigerator, LPA observed resident injectable medication that was not locked and accessible to residents in care. S2 immediately placed the medication inside the garage refrigerator and ordered lockable box. LPA also observed 3 pills in a medication cup inside one of the kitchen cabinet. S1 immediately removed the medication pills.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/24/2025
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Outdoor area was inspected. Facility has one exit gate. Pool was observed to be fenced, locked and not accessible at this time. Facility is equipped with solar powered generator. LPA observed the storage shed to be unlocked. Inside the storage shed, LPA observed sharp gardening tools and chemicals (photos were taken). S2 immediately locked the storage shed.

Fire extinguisher located in the kitchen was observed and were last inspected on 6/13/2025. Smoke and carbon monoxide detectors were observed and found to be working during this visit. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care, except for the injectable medication that was found in the kitchen refrigerator, cleaning supplies in one of the kitchen cabinet, scissors inside a kitchen drawer and sharp gardening tools and chemicals found inside the storage shed.

During an inspection of the garage with S2, LPA observed beddings to be propped up. Per interview with S2, staff does not use this garage as a sleeping area since this home has a staff bedroom.

Review of 4 resident files (R1, R2, R3 R4) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to ensure each resident have PRN authorization letter signed by their physician on file.

Medication review was conducted for 2 of the residents (R2 and R3). No issues were noted at this time.

Review of 3 staff files (S1, S2, and S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current.

Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan.

Administrator to submit current Liability Insurance Certificate, LIC500 and LIC308 to the Department.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit.

Exit interview was conducted and a copy of the report and appeal rights were provided upon exit.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2025 04:19 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/24/2025 at 04:03 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: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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. LPA observed the storage shed to be unlocked and observed chemicals and sharp gardening tools; LPA observed two scrissors in a kitchen drawer accessible to residents; LPA observed cleaning chemicals in a kitchen cabinet; 3 medication pills inside a medication cup inside one of the ktichen cabinet were accesible to residents; and LPA observed injectable medication inside the kitchen refrigerator that was accessible to residents. These pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Per discussion, administrator will submit a plan to conduct staff training; submit plan to the Department by POC due date.
Per discussion with the facility representative, S2 agreed to conduct staff training related to the deficiencies that were observed. Submit training to the Department once completed.
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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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