197607726-2-27-2024-31-AS-ERIS-D2UULP-20240227144104

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607726
Report Date: 02/27/2024
Date Signed: 02/27/2024 02:41:09 PM

Document Has Been Signed on 02/27/2024 02:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

FACILITY NAME:	WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTER		FACILITY NUMBER:	197607726
ADMINISTRATOR:	EDINA LEMUS		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	60	CENSUS: 45	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Edina Lemus		TIME COMPLETED:	03:00 PM

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 Analysts (LPAs) Evelin Rios, Michael Cava and Raymond Comer conducted an Annual Required visit and inspection of the facility. LPAs met with Administrator Edina Lemus, and explained the reason for the visit. Facility is fire cleared for fifty (50) non-ambulatory residents, and ten (10) bedridden for a total capacity of sixty (60) residents. Facility has a Hospice waiver for ten (10) residents. LPA's observed required postings through out the facility. The facility's smoke alarms are hard wired and facility conducts quarterly inspections. The Department of Forestry and Fire Protection and Champions Fire System Inc, conduct annual inspections. The fire extinguishers throughout the facility hallways, all extinguishers were last serviced on December 15, 2023. At approximately 11:30 a.m., with the assistance of the administrator and Chief of Plant Operations, Mordacious Mortem a tour of the physical plant was conducted and the following was observed. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms were checked and measured a range of 105.°F to 120°F and within the required range. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility; properly stored. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/27/2024

NARRATIVE

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Common Areas: Common areas, including two (2) activity rooms, (2) libraries, one (1) dining room, and sittings areas through out the facility appeared clean and were properly furnished.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The facility sectioned off areas that have active construction for resident safety.

Resident Files: LPA conducted a file review of five percent of the current census. LPAs reviewed resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: The medications were centrally stores in two locations. Medications were locked in medication cabinets, properly labeled and stored. Medication requiring refrigeration was observed in a locked refrigerator. Medication documentation was observed complete. Facility keeps electronic medication records. There are First Aid Kits through out the facility hallways.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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