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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 05:42:37 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
12/11/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20241211135010
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:
03:00 PM
MET WITH:Administrator Edina Lemus and Assistant Administrator Wendi Doyon TIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Staff do not ensure that resident needs are met.
Staff photographed residents without the resident's consent
INVESTIGATION FINDINGS:
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On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility for an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Administrator Edina Lemus and Assistant Administrator Wendi Doyon and explained the purpose of the visit. An entrance interview was conducted.

To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On 05/28/2025 LPA Rios interviewed seven (07) residents, the assistant administrator and five (05) staff.
(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-20241211135010
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) Allegation: Staff do not ensure that resident needs are met. Regarding the allegation, it was reported that staff are neglecting residents’ needs due to personal socializing during work hours. LPA’s interview with seven (07) out of nine (09) residents, denied staff’s socialization interferes with providing them or other residents with assistance. One (01) out of the seven (07) residents that provided information regarding the allegation stated staff will have small talk and socialize but are professional. Two (02) out of the nine (09) residents interviewed declined to comment or expressed that the issue was not of concern to them. Based on interviews, LPA was unable to corroborate the allegation. LPA did not find consistent evidence to suggest that staff socializing negatively impacts the care of residents. Therefore, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff photographed residents without the resident's consent. Regarding the allegation, it was reported staff are compromising residents' privacy and dignity by taking selfies in the dining room with residents in the background. To investigate the allegation LPA Rios conducted interviews with the facility administrator and staff #1 (S1), reviewed photo in question, and interviewed residents. The administrator and S1 confirmed that, on 12/11/24, during breakfast service in the dining area, staff members were observed engaging in personal activities unrelated to resident care—specifically, taking a selfie with a personal cell phone while residents were present in the background. S1 stated the photo was taken in a casual dining space—not during direct care—and believed the residents were not identifiable or the focus of the image. LPA’s review of the photo corroborated this, noting that residents in the background were not clearly identifiable. LPA’s Interviews with two (2) of nine (9) residents conducted on 04/14/25 and 05/28/25, revealed that they have witnessed staff using cell phones, though they could not determine whether usage was for personal or work related matters. One (1) of those two (02) residents recalled seeing a staff member take pictures but did not raise any concerns regarding the incident; this was confirmed to be unrelated to the event described in the allegation. LPA’s review of CalVet’s policy revealed that personal cell phone use is only allowed on breaks and away from residents, visitors, and other staff. While the use of personal cell phones during duty hours may conflict with internal facility policy, the specific allegation regarding photographing residents without consent is Unsubstantiated at this time.

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

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