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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 07/09/2025
Date Signed: 07/09/2025 05:41:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250529104617
FACILITY NAME:WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTERFACILITY NUMBER:
197607726
ADMINISTRATOR:EDINA LEMUSFACILITY TYPE:
740
ADDRESS:45221 30TH STREET WESTTELEPHONE:
(661) 974-7035
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:60CENSUS: 35DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator Edina Lemus and Assistant Administrator Wendi Doyon TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is not following food service sanitation practices.
Facility did not follow food safety guidelines when preparing food.
INVESTIGATION FINDINGS:
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On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Assistant Administrator, Wendi Doyon and later with Administrator Edina Lemus. LPA explained the purpose of the visit.

Allegation: Staff is not following food service sanitation practices. Regarding the allegation it was reported that staff used personal cellphones while serving meals and and did not use gloves while preparing food. To investigate the allegation LPA Rios conducted an initial complaint visit on 06/06/25. On 06/06/25 LPA Rios interviewed seven (07) out of thirty-six (36) residents or over 10% of the population. LPA Rios interviewed the administrator and six (06) staff. LPA also obtained and reviewed copies of the facility’s Hand Washing and Food and Nutrition Service Policies, along with documentation of in-service training sessions conducted on 12/02/24, 02/13/25, and 04/24/25. Job applications for food service staff were also examined to verify qualifications and experience. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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 31-AS-20250529104617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/09/2025
NARRATIVE
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(Continued from LIC9099) An additional staff interview was conducted on 09/09/25 at approximately 1:00 p.m. LPA's interview with seven (07) out of (07) residents 06/06/25 deny the allegation. Residents corroborate not witnessing staff on their cellphones while serving meals. LPA's interview with five (5) out of (07) staff denied seeing coworkers use cellphones while serving meals or failing to follow sanitation protocols. One (1) staff member noted that new employees occasionally need reminders to wear gloves, but confirmed that these issues were addressed before any incidents occurred. Another staff member acknowledged a past concern involving cellphone use but stated it had been resolved and had not occurred recently. Two (2) staff members reported having witnessed other staff use cellphones without washing their hands or changing gloves during meal service. One (1) of these staff also recalled seeing staff #1(S1) prepare food without gloves. However, the second staff did not corroborate that specific observation. LPA’s review of facility policy confirmed clear guidance on hand washing procedures, and documentation confirmed that staff had participated in multiple training sessions involving hand hygiene. Staff job applications reviewed by LPA revealed staff have appropriate qualifications to perform assigned food service duties. While some staff reported isolated concerns, the majority of resident and staff interviews did not corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Facility did no follow food safety guidelines when preparing food. Regarding the allegation it was reported that food felt under cooked. To investigate the allegation, LPA Rios conducted an initial complaint visit on 06/06/25. On 06/06/25 LPA Rios interviewed seven (07) out of thirty-six (36) residents or over 10% of the population. LPA Rios interviewed the administrator and six (06) staff. LPA also obtained and reviewed copies of the facility’s menu, residents that ate meals prepared by the facility, nurse's daily notes for 05/03/25, food temperature log, along with staff individual food safety training. LPA Rios also observed the kitchen and dining area on 06/06/25 during lunch time. LPA's interview with four (04) out of (07) residents interviewed on 06/06/25, stated they were satisfied with the quality and temperature of the food served and denied the allegation. LPA's interview with three (03) out of seven (07) residents reported that their meals felt colder than preferred, believing the food may have been undercooked. However, the residents did not reference the same meal or confirm a consistent issue. One (1) of the three noted that such concerns were in the past and that the food served more recently has improved. Six (06) out of (07) staff denied the kitchen staff do not follow food safety guidelines.

(Page 2 of 3)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250529104617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/09/2025
NARRATIVE
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(Continued from (LIC9099-C) five (5) acknowledged that one resident prefers food to be extremely hot and may return meals that do not meet that personal preference—even when temperatures are within regulatory range. Staff consistently stated that food is temperature checked after cooking and again while placed on the steam table prior to serving. LPA observed staff conduct temperature checks during lunch service, and all measurements were found to be within the appropriate range. Although some residents expressed personal preferences regarding food temperature, the investigation did not reveal consistent or corroborated evidence of undercooking or failure to follow food safety protocols. Based on LPA's observations and facility records, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Copy of report provided.

(Page 3 of 3)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3