197607726-10-14-2021-31-AS-NMAN-C93M2M-20211124081342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 10/14/2021
Date Signed: 10/14/2021 02:26:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/10/2019 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20190710105741

FACILITY NAME:	WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTER		FACILITY NUMBER:	197607726
ADMINISTRATOR:	ELVIE ANCHETA		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	60	CENSUS: 46	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elvie Ancheta - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility allowed residents to be in possession of inappropriate items
Facility staff failed to treat resident with dignity and respect
Resident(s) are not afforded privacy
Facility failed to provide a safe environment for resident(s) in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Eleza Jackson conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Administrator Elvie Ancheta and explained the reason for the visit.

LPAs conducted physical plant tour at 10:05 AM, requested facility documents relevant to the investigation at 10:30 AM and interviewed residents and staff between 10:30 AM to 1:00 PM. Regarding the allegation that Facility allowed residents to be in possession of inappropriate items, it was alleged that the facility allows residents to hide a machete, axe, sword, gun, or rifle under their mattress or inside of the closet. LPA Harriel's interview with Resident #1 (R1) on 07/28/19 at around 4:00 PM revealed that R1 did not mention any resident who possessed inappropriate items and R1 just hypothesized it. LPA's interview with the administrator today at 11:00 AM also revealed that she did not receive any report of any resident having any weapon or inappropriate items hidden in their rooms. Further, LPA's interview with staff at 11:00 AM also confirmed that they are not aware nor receive any report of any resident having inappropriate items hidden in own room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20190710105741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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-LANCASTER	FACILITY NUMBER: 197607726
	VISIT DATE: 10/14/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Facility staff failed to treat resident with dignity and respect, LPAs' interview with six (6) residents or more than 10% of the current census today between 10:30 AM and 1:00 PM revealed that six (6) out of six (6) residents did not experience nor witnessed discrimination at the facility and the staff are respectful and treat them with dignity. LPA's record review today at 12:37 PM also revealed that a similar allegation was lodged by R1 and was investigated by the Department of Veterans Affairs and was unsubstantiated.

Regarding the allegation that Residents are not afforded privacy, LPAs' interview with six (6) residents or more than 10% of the current census today between 10:30 AM and 1:00 PM revealed that six (6) out of six (6) residents were afforded privacy by the staff whenever they asked to.

Regarding the allegation that Facility failed to provide a safe environment for residents in care, it was alleged that R1 was given a "very threatening and menacing look" by Resident #2 (R2). LPAs' interview with R2 today at around 12:05 PM, revealed that R2 did not remember having encountered R1 nor R2 had any animosity with anyone at the facility during R2's stay here for five (5) years. LPAs record review today at 12:37 PM also revealed that R1 requested to the Administrator that R2 stopped talking to R1 which the administrator acted upon and had R2 agreed not to talk to R1.

Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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