Argonaut Care Home 3

Type of visit: Case Management - Incident

This is an amended report. Licensing Program Analyst, Arvin Villanueva (LPA) AMENDED this report which was previously entered on this facility in error on 8/19/2025. The exact report in its original form can be located on facility number 32701223. No citations were issued and a copy of this report was provided. This is an amended report. Licensing Program Analyst, Arvin Villanueva (LPA) AMENDED this report which was previously entered on this facility in error on 8/19/2025. The exact report in its original form can be located on facility number 32701223. No citations were issued and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 20, 2025

This is an amended report. Licensing Program Analyst, Arvin Villanueva (LPA) AMENDED this report which was previously entered on this facility in error on 8/19/2025.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: The exact report in its original form can be located on facility number 32701223. No citations and a copy of this report was provided.

Type of visit: Required - 1 Year

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. {1 of 2} 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. {2 of 2}the state’s words, verbatim · CDSS document, Jun 24, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 3/26/2025, at 10:13am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA met with Paulette Cameron, staff on duty (S1), and stated the purpose of this visit. S1 notified the facility supervisor Renae Earl of this visit and spoke with LPA over the phone. Renae is unable to come to the facility at this time and permitted S1 to sign this report. Present during today’s visit were 3 residents in care with 1 staff on duty. The purpose of this visit is to follow up on the submitted death report for Resident_1(R1) occurred on 9/10/24. Death report stated that R1 had passed away as a result of aspiration while eating dinner. The investigation into R1’s death consisted of interviews and record reviews. Review of R1’s death certificate confirms that R1 passed away on 9/10/24 due to cardiac arrest with dementia listed as a contributing condition. Other health issues were also noted including chronic diastolic heart failure. The time interval between the onset of cardiac arrest and death is recorded in minutes. No biopsy or autopsy was performed. A review of R1’s Coroner’s Report revealed that on 9/10/24, the responding deputy arrived and confirmed Cardiac Pulmonary Resuscitation (CPR) had been performed on R1 and continued by emergency personnel. Epinephrine and shocks were also administered, and intubation was attempted. All were not successful. It was also noted that R1 was struggling with eating dinner prior to death. Emergency services was summoned when R1’s condition worsen. Additionally, it was confirmed that R1 was not receiving hospice services. Based on the investigation, both death certificate and coroner’s report did not indicate R1’s death was questionable. {1 of 2} During this visit, LPA was informed by S1 that one of the current resident in care (R2) has bedridden status. Through interview, S1 explained to LPA that R2 does not get out of bed independently and that R2 is in bed all day. However, S1 noted that R2 can turn or reposition. During this visit, an outside agency staff (S2) arrived to visited R2. Through interview with S2, R2 is unable to independently reposition in bed or turn without assistance. Per observation, R2 is in the master's bedroom located near the fireplace at the living room area. According to the facility's license, bedroom #3 was approved for bedridden. Per review of R2's medical assessment (LIC602A) dated 9/13/2024 indicated that R2 is non-ambulatory which is counter indicative of what was noted through interview with S1 and S2. Per review of R2's admission agreement indicated that R2 was admitted to this facility on 9/9/2024. Following a discussion with Renae, it was noted that when R2 was admitted, they were nonambulatory status and R2's health gradually declined since then. LPA provided advisory that R2 be reassessed by their physician to ensure their ambulatory status is accurately documented. During this visit, LPA obtained copy of relevant documents relating to R2 for review. LPA will conduct a facility file review to confirm which is bedroom #3. LPA will follow up with the facility staff regarding updates on R2's ambulatory status. Exit interview was conducted with Renae over the phone and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Sep 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 2, 2024

(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: 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.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 6/13/24 at 1:00pm. LPA observed the Administrator Certificate expires on 10/05/2024 for Mama Ngaima. LPA met with Shadae James, Designee and stated the purpose of todays visit. The most recent emergency drill was conducted on 5/14/24. The facility is licensed for a capacity of 6 residents of which 1 may be bedridden in room 3. Hospice waiver approved for 2 to receive hospice care services. There is 0 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 114.5*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 1 staff and 1 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610D-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-Submit (if Applicable) Infection Control Plan-Submit Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Case Management - Other

On 2/13/2024 at 10:08am Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management continuation visit to continue the post licensing initiated on 12/28/2023 and issue additional deficiencies from the continuation visit on 2/7/24. LPA initially met with the staff on duty and explained the purpose of today’s visit. The facility supervisor, Shadae James was informed of the visit and arrived shortly after. Present during this visit were 2 residents in care with 1 staff on duty. During this visit, LPA issued the remaining deficiencies cited from the case management annual continuation visit on 2/7/24. Also during this visit, LPA provided technical assistance to the facility supervisor on maintaining personnel records in the facility and making sure records are available for review by the Department any time. Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Failure to correct deficiencies may result in civil penalties. Interview was held with the Shadea and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 2/7/2024 at 10:15am Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management continuation visit to continue the post licensing initiated on 12/28/2023. LPA initially met with the staff on duty and explained the purpose of today’s visit. The facility supervisor was informed of the visit. Present during this visit were 2 residents in care with 1 staff on duty. From last visit, LPA was having technical issues with the CARE Tool. During this visit, the CARE Tool is still not accessible for utilization. During this visit, LPA conducted facility observation, resident file reviews, medication reviews, staff file reviews and facility file reviews. During the facility observation, LPA observed residents in care watching TV throughout the visit. Staff on duty interacted with residents every now and then. No other activities were offered to residents. Water temperature in 1 of 3 bathrooms was measured at 117 degrees F. Room temperature during this visit was measured at 71 degrees F. Facility have adequate food supplies with 2-day perishables and 7-day non-perishables were maintained for 2 residents. Overall, the facility was observed to be cleaned and free of obstructions. During the observation of the kitchen refrigerator, LPA observed an insulin injection pen stored in the refrigerator. LPA did not observe a thermometer in the refrigerator and unable to determine the temperature. Thermometer reading in the freezer was observed to be at 0 degree F. During staff file review, LPA observed 3 of 3 staff files that were available for review were observed to be incomplete. Additionally, 1 of 3 staff files are not available for review during this visit. Administrator's files are also not available for review at this time. Per staff, the files are not in the facility upon request. {Con't to LIC809-C} {Con't from LIC809} During resident file reviews, 2 of 2 resident files available for review were observed to be incomplete. 1 of 2 resident files were observed to be missing the needs and services plan. 2 of 2 resident files were observed to have missing PRN Authorization signed by their physicians. During medication review, LPA observed the following: some medications are expired, some medications were not recorded in the centrally stored medication form (LIC622), some medications do not have physician's order available for review, some prescribed medications are not available for review. Per review of the facility's medication administration record (MAR), 4 medications were observed to be missing staff initials since 2/1/2024. Due to insufficient time, this post-licensing will require a continuation visit. The Department will return at a later date to complete the issuance of additional deficiencies. Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Failure to correct deficiencies may result in civil penalties. Interview was held with the the staff on duty and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 7, 2024

Type of visit: Post Licensing

On 12/28/23 at 9:45am Licensing Program Analysts (LPAs) Christina Valerio and Arvin Villanueva conducted an unannounced post licensing visit, with the use of the CARE Inspection Tool. LPA initially met with the staff on duty and explained the purpose of today’s visit. The administrator was informed of the visit. The facility is currently licensed to serve 6 non-ambulatory elderly residents, of which 1 may be bedridden. Room #3 from the facility sketch is cleared for 1 bedridden resident. The facility is approved for 2 hospice residents. Currently, the facility has no hospice and/or bedridden residents in care. Present during this visit were 3 residents in care with 1 staff on duty. Also present during this visits were outside agency nurses/professionals. At 10am LPAs inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There is a swimming pool on the premises located in the backyard that is fenced, locked, and inaccessible to residents in care. Outside of the facility was observed to be clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and area with outdoor umbrella for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed 3 resident bedrooms and 2 bathrooms for resident use. Resident bathrooms were operational and adequately supplied including with grab bars and non-skid flooring. A third bathroom is observed to be for employee used only. LPAs observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. {Con't to LIC809-C} {Con't from LIC809} LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 74 degrees F. Water temperature in one of the bathroom was measured at 116 degrees F. Fire extinguisher was serviced on 5/21/23. Smoke detectors and carbon monoxide were tested and found to be operable during this visit. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed complaint information posted. Facility has appropriate internet access available for resident use. LPA observe facility’s equipment and supplies to meet activity program needs of residents in care. During this inspection, LPAs conducted an audit of facility files, 3 of 3 resident files, and 1 staff file for regulatory compliance. During this visit, only 1 staff file was available for review. The facility is current on annual license fees. Updated facility LIC500 was not available for review during this visit. LPAs attempted 2 resident interviews and 1 staff interview. LPAs could not confirm if facility conducts quarterly fire/disaster drills as there is no records of drills available during this visit. Due to technical issues, LPA will return at another date until the issue can be resolved to continue with the post-licensing visit.the state’s words, verbatim · CDSS document, Dec 28, 2023