<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607726
Report Date: 06/23/2020
Date Signed: 06/23/2020 11:00:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTERFACILITY NUMBER:
197607726
ADMINISTRATOR:ELVIE ANCHETAFACILITY TYPE:
740
ADDRESS:45221 30TH STREET WESTTELEPHONE:
(661) 974-7035
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:60CENSUS: 58DATE:
06/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Elvie Ancheta/ AdministratorTIME COMPLETED:
11:00 AM
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
Licensing Program Analyst (LPA) Patrick Shanahan conducted an unannounced telephone visit for the purposes of following up on the confirmation of removal regarding staff#1(S1). LPA spoke with Elvie Ancheta, Administrator and explained the purpose of the visit.

Confirmation of removal letter generated on 6/19/2020 was received from Caregiver Background Check Bureau for Staff#1(S1). The notification states the individual must be removed from facility because he/she has been convicted of a crime and an exception has not been granted. Administrator confirmed that S1 was never hired at the facility nor had they worked there.

During this visit, LPA obtained a copy of the LIC 500 and S1's name was not present on the roster.

Based on the evidence obtained during today's visit, LPA verified that the S1 is not present, employed, or residing at the facility.

Exit interview conducted and a copy of this report issued. Due to the Covid-19 Pandemic, LPA was unable to get a signature from the administrator in person. This report was emailed to the administrator and "wet" signature was acquired and will be in the facility hard file.
SUPERVISOR'S NAME: Maryjo SchnitzerTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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 1