197607726-4-14-2025-31-AS-ERIS-DFR2MF-20250414173103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607726
Report Date: 04/14/2025
Date Signed: 04/14/2025 05:31:15 PM

Document Has Been Signed on 04/14/2025 05:31 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTER		FACILITY NUMBER:	197607726
ADMINISTRATOR/ DIRECTOR:	EDINA LEMUS		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 60		CENSUS: 38	DATE:	04/14/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Edina Lemus		TIME VISIT/ INSPECTION COMPLETED:	05:35 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	On 04/14/25, at approximately 9:30 a.m., LPA Evelin Rios conducted an unannounced annual continuation case management visit. Upon arrival, LPA signed in at reception as requested by the security guard. LPA was then greeted by Supervisor Psychiatric Social Worker Seema Misra, who escorted LPA to the Administrator's office. There, LPA met with Administrator Edina Lemus and explained the purpose of the visit. During the initial annual visit on 12/16/24, the facility had completed the required corrective actions noted in its fire and life safety inspection from 06/10/24. As part of today’s assessment, LPA reviewed the facility’s fire and life safety re-inspection report dated 02/19/25. The inspection confirmed the facility had passed. Additionally, LPA reviewed the annual inspection report conducted by the County of Los Angeles Fire Department, which showed no deficiencies. LPA also examined the facility’s infection control plan, fire drill records, and after-action reports for both the "Shake Out" drill and the reception of West Los Angeles RCFE residents affected by the Palisades Fire. From approximately 11:06 a.m. to 12:00 p.m., LPA, assisted by Staff Services Manager I, Annette Barrera, and Nurse Instructor Takira Florence, reviewed seven (07) staff records to ensure compliance with licensing requirements and up-to-date training. From 1:00 p.m. to 3:30 p.m., LPA reviewed six (06) resident records for completeness and adherence to licensing standards. No issues were observed during the review. During the initial annual visit on 12/16/24, LPA toured three (03) shared rooms. On today’s visit, LPA toured two (02) additional shared rooms. All rooms were appropriately furnished and had sufficient lighting. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTER	FACILITY NUMBER: 197607726
	VISIT DATE: 04/14/2025

NARRATIVE

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During today's visit, two (02) residents confirmed that housekeeping regularly cleans their rooms. One (01) resident, however, stated they decline cleaning services. The Administrator is aware of the resident’s refusal and continues to engage in ongoing discussions regarding their preferences.

During the initial annual visit on 12/16/24, LPA toured three (03) resident bathrooms. On today’s visit, two (02) additional bathrooms were inspected. All bathrooms were found to be clean and equipped with the required grab bars, non-slip flooring, and an adequate supply of toilet paper and hand soap.

Medications are centrally stored in two designated locations. All medications were observed to be securely locked in medication cabinets, properly labeled, and stored according to regulations. Medications requiring refrigeration were appropriately stored in a designated refrigerator. With assistance from Barbara Fahey, LPA reviewed both the medication and electronic medication records, as well as observed the medication assistance process. No issues were noted.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit interview conducted. Copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC809 (FAS) - (06/04)

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