032701225-9-21-2026-27-AS-KVIA-DY5UVS-20260921155537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 032701225
Report Date: 09/21/2026
Date Signed: 09/21/2026 03:56:45 PM

Document Has Been Signed on 09/21/2026 03:56 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 3		FACILITY NUMBER:	032701225
ADMINISTRATOR/ DIRECTOR:	SHADAE JAMES		FACILITY TYPE:	740
ADDRESS:	10575 RIDGECREST DR.		TELEPHONE:	(209) 268-0597
CITY:	JACKSON	STATE: CA	ZIP CODE:	95642
CAPACITY: 6		CENSUS: 3	DATE:	09/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Paulette Cameron, Designee		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 09/21/26. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator, Shadae James. James was not on the premises and staff stated they would not be in today. LPA met with Designee, Paulette Cameron. LPA had emailed a list of documents (below) to be collected during this visit. These documents included: LIC 500: Personnel Report; please update and remove any staff no longer employed and include all new hires in Guardian. To associate someone to your facility, submit your fingerprint transfer to sactranfserrequest@dss.ca.gov. A copy of your Resident/Client Roster LIC 308: Designation of Administrative Responsibility LIC 309: (for any LLC or Corp) if applicable LIC 402: Surety Bond, if applicable LIC 610E: Emergency Disaster Plan Copy of Liability Insurance An updated lease agreement, if applicable. An updated Facility Sketch (The LIC 500 and LIC 308 were not available at the facility at the time of this inspection.) LPA observed an Administrator's certificate posted by the front door for Chukwudi (Patrick) Ikiseh, # 7029096740 which expires on 10/06/26. The last change of Administrator processed by Community Care

Lisa Rios
Kimberly Viarella
	DATE: 09/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

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 14

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)

Page: 2 of 14

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: 09/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensing (CCL) was for Shadae James on 02/06/26 and James was the Administrator of record.

LPA inspected 3 resident rooms. All had the required furniture, furnishings and lighting to be in compliance at the present time.

The LPA inspected the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable.

LPA inspected a total of 2 resident bathrooms. Each contained soap, paper towels, trash cans and grab bars as required. Showers had non-skid surfaces for safety purposes. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance. Hot water measured 117.7 degrees and was in compliance at the time of this inspection.

The fire extinguishers (1 in the kitchen, 1 in the garage) were last serviced on 07/15/26 by Sierra Foothill Service Fire Extinguisher Company and were in compliance at the time of inspection.

The LPA observed medications were stored in a locked closet near the front door and inaccessible to residents in care. LPA observed bins for each of the current residents along with a bin for a resident no longer at the facility. The medication in that bin should have been disposed of in a timely manner. This deficiency has been cited on the LIC 809D page. LPA reviewed storage, dosing, and destruction procedures with Designee. LPA informed the Designee regarding the requirement for over-the-counter medications like Tylenol to have prescriptions on file. A review of the First Aid kit by the LPA found it to be complete and in compliance.

The exterior of the building was inspected by the LPA. There were sitting areas in shaded locations residents and their guest to enjoy. There was an in-ground pool that was completely fenced in, locked and inaccessible to residents in care. The yard was completely fenced in and the LPA provided consultation services regarding the height of the fence along the rear of the yard where there was a steep drop on the other side. The sliding doors in the master bedroom were missing a screen, as was the window in the staff bedroom. This deficiency was cited on the LIC 809 page. The gutters and grounds were in good repair and free on debris.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

LIC809 (FAS) - (06/04)

Page: 3 of 14

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: 09/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed the facility license, administrator's certificate, grievance policy, and IF YOU SEE SOMETHING, SAY SOMETHING sign. Resident Rights were not posted as well as the last CCL report. These deficiencies were also addressed on the LIC 809 D page.

LPA conducted a sample file review. LPA compared the staff roster to the Community Care Licensing's (CCL's) LIS roster to ensure all staff had the appropriate background clearances. Both were in compliance at the time of this inspection. LPA reviewed 1 of the 2 staff files as the second file was not at the facility. The file for S1 was in compliance however, the date for their last TB test needs to be forwarded to CCL. LPA reviewed the files for the 2 current residents. Resident 1 was missing an updated LIC 602, this Deficiency was cited on the LIC 809D page. Resident 2's file was complete.

According to the California Code of Regulations, Title 22, any deficiencies observed were cited or technical assistance/violations were provided during today's visit. A copy of this report was provided and an exit interview was conducted with the Designee.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

LIC809 (FAS) - (06/04)

Page: 4 of 14

Document Has Been Signed on 09/21/2026 03:56 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 09/21/2026 at 01:16 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: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.626(a)

Other Provisions

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on document review, 1 out of 2 staff files were missing from the facility so this LPA could not ensure that all the required training had been completed. This posed/poses a potential threat the health safety and personal rights of residents in care.
	POC Due Date: 09/30/2026
	Plan of Correction
1 2 3 4	The Designee stated that the file for S2 will be at the facility by the close of business on 9/28/26. A copy of their LIC 501, CPR /First Aid Certification and training will be emailed to LPA Kimberly Viarella at Kimberly.viarella@dss.ca.gov.

Type B

Section Cited

CCR

87463(b)

Reappraisals

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on document review and LPA observations, R1 was hard of hearing, nonambulatory , and had a medical condition not listed on their LIC 602 dated 2024. If these observations were reported a reappraisal should have been conducted. poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2026
	Plan of Correction
1 2 3 4	Designee stated that Licensee will ensure that R1 obtains a new LIC 602 and that their care plan reflects their new needs. This will be completed by 10/21/26 and a copy will be sent to Kimberly.viarella@dss.ca.gov by the close of business on 10/21/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

LIC809 (FAS) - (06/04)

Page: 5 of 14

Document Has Been Signed on 09/21/2026 03:56 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 09/21/2026 at 03:41 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: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87613(a)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, S1 was not trained to oversee R1 checking their glucose and administering their own insulin injections poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2026
	Plan of Correction
1 2 3 4	The Designee stated that the Licensee will ensure that S1 will receive apropriate training from a licensed professional regarding the special health needs of R1 by the close of business on 10/09/26. Documentation of this training with the names and contact information of the trainer along with the material covered will be sent to Kimberly.viarella@dss.ca.gov.

Type B

Section Cited

HSC

1569.618(a)

Administrator Qualifications: ...shall be present duirng working hours... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on document review the Designated Facility Administrator has been scheduled to work 7:00PM - 7:00 AM. This poses(ed) a potential risk to the health, safety and personal rights of residents in care.
	POC Due Date: 09/28/2026
	Plan of Correction
1 2 3 4	The Designee stated that the Licensee will submit a new schedule with hours compliant to the above regulation by the close of business on 09/28/26 to Kimberly.viarella@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

LIC809 (FAS) - (06/04)

Page: 14 of 14