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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 08/13/2025
Date Signed: 08/13/2025 04:34:20 PM

Substantiated


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: 36DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Edina Lemus, Administrator and Wendi Doyon, Assistant AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Residents are not allowed privacy.
INVESTIGATION FINDINGS:
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On 08/13/2025, 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 Assistant Administrator Wendi Doyon and Administrator Edina Lemus. The purpose of the visit was explained, and an entrance interview was conducted.

LPA Rios conducted a physical plant tour of the facility and did not observe any immediate health or safety concerns.

Allegation:Residents are not allowed privacy. Regarding the allegation, it was reported that residents are not accorded privacy during sensitive conversations with Veterans Service Officer (VSO). LPA’s review of the CalVet website found that VSOs work directly with individual veterans and their families to ensure veterans receive benefits they earned through their service.
(Cont. to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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: 08/13/2025
NARRATIVE
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(Cont. from LIC9099) To investigate this allegation, LPA Rios interviewed the Administrator on 07/09/2025. The Administrator explained that the VSO had previously been teleworking and conducting resident meetings by telephone, which allowed residents the opportunity to discuss topics in private. However, the VSO has since transitioned to working from a cubicle and would schedule appointments in a small conference room when meeting with residents.

During today's visit the Assistant Administrator informed LPA the VSO was no longer working for the facility and provided LPA a tour of the cubicles the VSO would have used when working at the facility. LPA Rios also interviewed four (04) residents or approximately 10 percent of the facility’s population and one (01) staff member. Resident #1 (R1) and Resident #2 (R2) both reported that they did not have privacy during their appointments with the VSO. They stated not verbatim, that meetings were held in a cubicle within arm’s length of another person and that they were not offered the option of a private room. Resident #3 (R3) had not personally met with the VSO but reported hearing complaints from other residents expressing discomfort with the lack of privacy during cubicle meetings. Resident #4 (R4) did not recall meeting with the VSO. R3 added that although they personally did not mind the lack of privacy, they understood why others might be concerned. They did not consider the information discussed to be sensitive but acknowledged that privacy expectations vary among individuals.

LPA’s review of the facility’s HIPAA privacy policy found that while staff are required to receive appropriate training, training alone does not replace the need for physical safeguards to protect resident privacy. Based on the information obtained through resident interviews and LPA’s own observations, the allegation that residents are not allowed privacy during VSO appointments is deemed Substantiated at this time.

Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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The Administrator agreed to conduct an action plan that will be implemented to allow for private meetings in a closed conference room. Plan will be emailed to LPA by the POC due date.
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Based on LPA's observation and interviews, the licensee did not comply with the section cited above by not providing privacy and conducting VSO appointments in a cubicle by other staff, which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
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