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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 032701224
Report Date: 12/19/2025
Date Signed: 12/19/2025 03:50:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2025 and conducted by Evaluator Arvin Villanueva
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250602153344
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:0CENSUS: 0DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Shadae JamesTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not prevent a resident from developing a stage 4 pressure injury while in care.
Staff are serving cold meals to residents in care.
Staff left a resident in a soiled diaper for a long period of time.
INVESTIGATION FINDINGS:
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On 12/19/25, Licensing Program Analyst, Arvin Villanueva (LPA) conducted an in-person meeting with facility representative, Shadae James, to deliver complaint findings regarding the allegations noted above. Note that Argonaut Care Home 2 is closed as of 9/24/2025. This in-person meeting was held at Argonaut Care Home, Inc (facility #32701223).

Throughout this investigation, LPA reviewed medical records, hospice notes, facility documents, and also interviewed staff and the administrator. Records showed that R1 was admitted to this facility on March 29, 2025, and already had several medical problems, including a history of skin breakdown. R1’s Physician’s Report stated that R1 was bedridden, unable to transfer on their own, and needed help with almost all daily tasks. R1 also used a Foley catheter and had a known history of skin issues.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20250602153344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2025
NARRATIVE
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R1’s Needs and Services Plan and Appraisal both showed that R1 needed help with bathing, dressing, toileting, and moving around, and that he sometimes became confused.
Hospice records showed that nurses and home health aides visited R1 periodically and provided wound care, changes, catheter care, and hygiene support. The subpoenaed hospice documents confirmed that R1 already had pressure sores and other injuries before moving into the facility.
The administrator (AD) stated that R1 came into the facility with the sores and that hospice was notified right away. AD also explained that R1 sometimes refused to be changed, and staff would encourage R1 when this happened. Staff interviewed denied leaving residents in soiled diapers and said they changed residents as needed.
Based on all the information gathered and reviewed, the preponderance of evidence of standard is not met. Therefore, the allegation that the facility caused R1’s pressure injury or failed to prevent it was UNSUBSTANTIATED
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The investigation into the allegation that staff are serving cold meals to residents consisted of LPA reviewing screenshots of group text messages between the administrator and several staff members. The messages showed routine communication about daily tasks and short notes about residents, including a handwritten list of food items. However, the screenshots did not include any comments about food temperature, or any complaints from residents or staff about cold food. There were no time stamps, and no information showing how meals were prepared or served. Because of this, the screenshots did not provide evidence to support the allegation.

The LPA also interviewed staff on duty (S1) on 6/4/25, which they stated that the facility does not serve cold meals unless the food is supposed to be cold, such as sandwiches. S1 explained that meals are served warm and that they have not seen staff give residents cold food.

During an interview with Administrator Chukwudi Patrick Ikiseh (AD), stated that the facility does not serve cold meals unless the menu calls for a cold item. AD explained that staff often send him photos of the food they prepare, and he monitors meal quality through these messages. He said there have been no complaints from residents about cold food.

Based on the information gathered, the preponderance of evidence is not met. Therefore, the allegation is UNSUBSTANTIATED.

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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250602153344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2025
NARRATIVE
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The investigation into the allegation that staff left Resident 1 (R1) in a soiled diaper for a long period of time. Consisted of reviewing R1’s medical records, hospice notes, facility documents, and interviewed staff and the administrator. Records showed that R1 was admitted to facility on March 29, 2025, and had several medical conditions, including a history of skin breakdown. R1’s Physician’s Report stated that R1 was bedridden, unable to transfer on their own, and needed help with almost all daily care tasks, including toileting and hygiene. R1 also used a Foley catheter and sometimes became confused.

R1’s Needs and Services Plan and Appraisal both showed that full assistance was required with bathing, dressing, toileting, and moving around the facility. Hospice records showed frequent visits from nurses and home health aides who provided bed baths, catheter care, wound care, and monitored R1’s hygiene. Hospice notes documented consistent care and did not report concerns about R1 being left in soiled conditions. Subpoenaed hospice documents also confirmed that R1 had injuries, including pressure sores, before moving into the facility, and that hospice continued to follow up on his care while he lived there.

During an interview, Staff 1 (S1) stated they have not worked at the facility long but denied ever leaving residents in soiled diapers. S1 explained that residents are changed when needed. The administrator, Chukwudi Patrick Ikiseh, stated that R1 sometimes refused to be changed, and staff would encourage R1 when this happened.

Based on the record review, hospice documentation, staff interviews, and the administrator’s statements, the preponderance of evidence is not met, therefore, the allegation is UNSUBSTANTIATED.

Note that an unsubstantiated finding means that although the allegation may have happened the preponderance of evidence does not prove it.

No deficiencies were cited as a result of this visit. An exit interview was conducted with Shadae James and a copy of this report and appeal rights were provided.



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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3