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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701224
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:57:52 PM

Document Has Been Signed on 11/27/2023 03:57 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: 3DATE:
11/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff on dutyTIME COMPLETED:
04:30 PM
NARRATIVE
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On 11/27/23 at 9:30am, Licensing Program Analysts (LPA) Christina Valerio and LPA Arvin Villanueva arrived to the facility unannounced to conduct a post-licensing inspection. LPAs initially met with staff on duty and explained the purpose of the visit. Administrator Chukwidi "Patrick" Ikiseh arrived shortly after. During this visit, there are two (2) staff on duty with three (3) residents in care. Facility is COVID-free status.

At 10:00am LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, other common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a single-story home with a fire clearance to serve 6 non-ambulatory elderly residents with approved 1 bedridden resident in bedroom #1. Facility also has a waiver for 2 hospice residents and has been licensed to retain residents with dementia. Facility has 4 resident bedrooms, and 2 bathrooms for resident use. LPA observed both bathrooms to contain grab bars, non-skid flooring, shower chairs, close lid trash containers and hygiene supplies. Resident bedrooms were sanitary, furnished, well-lit and had adequate storage for resident’s belongings.

The facility common areas are cleaned and furnished. Facility has a dining area off the kitchen and a formal living room. In the kitchen area, LPAs observed to be sanitary and free of clutter. Additionally, the kitchen knives and other sharp objects are kept in a locked drawer. Toxins and cleaning supplies are kept locked and inaccessible to residents in care. LPAs observed the facility to have adequate food supply with at least 2 days’ worth of perishables and 7 days’ worth of non-perishables. LPAs observed functioning washer and dryer on the way to the garage. In the garage, LPAs observed an additional fridge and couches/futons.

Water temperature reads 105*F to 120*F in 1 of 2 bathrooms; and room temperature reads 76*F. Smoke and carbon detectors were in good repair. Fire extinguisher was serviced on 15/19/23. Medication storage area was observed to be locked and inaccessible to residents in care. Medication records for 1 of 3 residents were reviewed and observed to be not in compliance with regulation. First aid kit was observed to have adequate supplies and accessible to staff. {Con't to LIC 809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 01:40 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 of 2 staffing files having health screen and TB test done older than 6 months prior to hiring date which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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The licensee to set a schedule for staff obtain a health screening/TB Test and submit the schedule date to the Department by POC due date.
Type A
Section Cited
CCR
87465(e)
(e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication record review, the licensee did not comply with the section cited above in 1of 3 residents in care having 3 medications that was observed to not contain medication label from the pharmacy which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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Licensee to plan to obtain a precription labels for medications without labels. The plan to obtain the labels from the pharmacy is to be submitted 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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 01:40 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: 11/27/2023

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 interview and record review], the licensee did not comply with the section cited above in 1 of 2 staff files and administrator's file being incomplete and not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to submit a declaration of understading of the regulation CCR 87412(f) to the Department by the POC due date.
Licensee to ensure staff and administrator's files are kept and available for review in the facility.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review], the licensee did not comply with the section cited above in 1 of 2 staff files and administrator's file being incomplete and not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to submit a declaration of understading of the regulation CCR 87412(a) to the Department by the POC due date.
Licensee to ensure staff and administrator's files are kept and available for review in the facility.
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 01:40 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(a)(1)(A)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (A) Four (4) hours of instruction in laws, regulations, policies, and procedural standards that impact the operations of residential care facilities for the elderly, including but not limited to the authority referenced in this Chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review and interview, the licensee did not comply with the section cited above as administrator's file was not in the facility and was not available for review to confirm required trainings were completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to submit a declaration of understading of the regulation CCR 87406(a)(1)(A) to the Department by the POC due date.
Licensee to ensure staff and administrator's files are kept and available for review in the facility.

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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 01:40 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 of 2 staff files and administrator's file being incomplete and not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to submit a declaration of understading of the regulation CCR 87412(d) to the Department by the POC due date.
Licensee to ensure staff and administrator's files are kept and available for review in the facility.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 of 2 staff files being incomplete and not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to submit a declaration of understading of the regulation HSC 1569.267(d) to the Department by the POC due date.
Licensee to ensure staff and administrator's files are kept and available for review in the facility.
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 01:40 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(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.

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 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.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee to schedule staff training and submit the date of training to the Department by the POC due date.
Licensee to submit proof of training once training is completed.
Type B
Section Cited
CCR
87633(b)(6)(A)
Hospice Care for Terminally Ill Residents
(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. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control.

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 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.
POC Due Date: 12/04/2023
Plan of Correction
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3
4
Licensee to schedule staff training and submit the date of training to the Department by the POC due date.
Licensee to submit proof of training once training is completed.
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 6 of 13
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: 11/27/2023
NARRATIVE
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{Con't from LIC809}

During this inspection, 3 resident files and 2 staffing files were reviewed for regulatory compliance. 2 of 3 resident files were observed to be not in compliance with regulations. LPAs also observed 1 of 2 staffing files to be not in compliance with regulations. Review of staffing timesheet binder reveals no evidence of night supervision. Additionally, administrator's files were not available for review during this visitl. LPAs completed 1 staff interview and attempted resident interviews. LPAs record review revealed no evidence of quarterly fire drills available for review. LPAs also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. LPAs requested an updated copy of Liability Insurance, LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Interview was held with the Chukwudi Ikiseh and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 11/27/2023 03:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/27/2023 at 03:38 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
(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 facility record review, the licensee did not comply with the section cited above as there is no evidence of fire drill was done since licensure which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Corrected during visit. Licensee submitted document from last fire drill dated 10/29/23.
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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