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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701224
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:37:39 PM

Document Has Been Signed on 03/06/2024 04:37 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 2FACILITY NUMBER:
032701224
ADMINISTRATOR:IKISEH, CHUKWUDIFACILITY TYPE:
740
ADDRESS:840 ARGONAUT DR.TELEPHONE:
(209) 268-0597
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff on dutyTIME COMPLETED:
04:45 PM
NARRATIVE
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On 3/6/24 at 1pm, Licensing Program Analysts (LPA) Arvin Villanueva arrived at the facility to conduct an unannounced Plan of Correction (POC) visit. LPA initially met with the staff on duty and explained the purpose of the visit. The facility administrator, Chukwudi Ikiseh, was notified of the visit via telephone. LPA spoke to the administrator via telephone and explained the purpose of the visit. The purpose of this visit was to verify the plan of correction that was required to be completed on 11/28/23 and 12/4/23 for deficiencies that were previously cited on a prior visit conducted on 11/27/2023. Present during this visit are 4 residents in care with 1 staff on duty.

Upon arrival to the facility, LPA observed a medicine cup filled with medication pills. On the cup, a resident's name is on it. Per interview with staff on duty, the resident is currently sleeping and not ready to take the medication pills. Staff on duty put away the medication. During staff file review, LPA observed 2 of 3 staff have expired first aid certificate. Additionally, files for the above administrator, Chukwudi Ikiseh is not available for review during this visit.

Based upon this inspection, LPA Villanueva observed the following:
  • The deficiency cited under Title 22 Regulation 87465(e) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(a)(11) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(f) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Title 22 Regulation 87412(a) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. LPA observed during today's POC visit that the administrator's file is not present at this facility and not available for review at this time.
Con't to LIC809-C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 4
Document Has Been Signed on 03/06/2024 04:37 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/06/2024 at 03:28 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 2
FACILITY NUMBER: 032701224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2024
Section Cited
CCR
87465(h)(2)

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(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:
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Licensee to provide training to staff regarding medication administration. Date of staff training to be submitted to the Department by POC due date.
Proof of training to be submitted to the Department once training is completed.
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Based on observation, the licensee did not comply with the above regulation as LPA observed resident medicatiosn dispensed in a medicine cup, placed on top of the dining table during the visit (photo was taken). This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
03/13/2024
Section Cited
HSC1569.695(c)

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(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.
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Licensee to submit proof of current quarterly fire drills to the Department by the POC due date.
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This requirement is not met as evidenced by:
Based on facility record review, the licensee did not comply with the section cited above as there is no evidence of fire drill was done after 10/29/23, 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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/06/2024 04:37 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/06/2024 at 03:54 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 2
FACILITY NUMBER: 032701224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
87633(b)(6)

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(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.
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Licensee will ensure all staff receive hospice care training that meets requirements. Licensee will submit evidence of staff training to the department by the POC due date.
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This requirement is not met as evidenced by:
Based on record review and interview, the licensee did not comply with the section cited above as there is no evidence of hospice training available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
03/13/2024
Section Cited
CCR87411(c)(1)

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(c) All RCFE staff who assist residents with personal activities of daily living...
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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Licensee to ensure 2 of 3 staff will complete First Aid Training and submit to CCLD by POC date.
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Based on record review and staff interview, licensee did not comply with the section cited above in 87411(c)(1). Based on on bservation, 2 of 3 staff files reviewed do not have current first aid training which poses a potential health and safety risk to residents 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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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 2
FACILITY NUMBER: 032701224
VISIT DATE: 03/06/2024
NARRATIVE
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  • The deficiency cited under Title 22 Regulation 87406(a)(1)(A) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. LPA observed during today's POC visit that the administrator's file is not present at this facility and not available for review at this time.
  • The deficiency cited under Title 22 Regulation 87412(d) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. LPA observed during today's POC visit that the administrator's file is not present at this facility and not available for review at this time.
  • The deficiency cited under Health and Safety Code 1569.267(d) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  • The deficiency cited under Health and Safety Code 1569.695(c) has been cleared. Licensee complied with the terms of the POC by POC due date. POC was corrected during the post-licensing visit on 11/27/23 by providing LPA documentation of fire drill conducted on 10/29/23. A POC letter was generated and provided to the licensee. During today's visit, LPA reviewed facility documentation for fire/emergency drill. From the document review, LPA did not find subsequent quarterly fire/emergency drills.
  • The deficiency cited under Title 22 Regulation 87633(b)(6) has not been cleared. Licensee did not comply with the terms of the POC by POC due date. LPA only received training completion of one staff for this citation. There were no other hospice training documentation to review during today's visit.
  • The deficiency cited under Title 22 Regulation 87633(b)(6)(A) has not been cleared. Licensee did not comply with the terms of the POC by POC due date. LPA only received training completion of one staff for this citation. There were no other hospice training documentation to review during today's visit.

Immediate civil penalties are being assessed due to repeat violations. The facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.


As a result of this case management, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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