197607726-11-3-2021-31-AS-NMAN-C93M2L-20211124081342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:04:42 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: 44	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Elvie Ancheta - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff threatened resident in care
Facility staff search residents room's without warrant
Facility staff refused to provide resident with food

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 10:30 AM, requested and reviewed facility documents relevant to the investigation from 11:00 AM to 12:30 PM. Interviewed the administrator and staff between 12:30 PM to 1:30 PM. Regarding the allegation that Facility staff threatened resident in care, it was alleged that a staff threatened the resident to call 911 when the resident refused to allow the staff to search the resident's room for alcohol. LPA Diaz' interview with Resident #1 (R1) on 02/25/20 at around 2:16 PM, revealed that R1 did not feel threatened but disappointed and hurt R1's feelings. LPA Diaz's interview with the administrator on 07/18/19 at around 3:10 PM, also revealed that she did not receive any report of any staff threatening any resident.

(continued on LIC 9099-C)

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: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: 11/03/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Facility staff search residents room's without warrant, it was alleged that a staff burst into a resident's room asking to search for an alcohol bottle. LPA Diaz's interview with R1 on 02/25/20 at around 2:16 PM, revealed that R1 was pulled over by a facility security guard outside of the community and when asked, denied having alcohol inside own room. LPA's record review today between 11:00 AM to 12:30 PM also revealed that the facility are required by the Department of Veterans Affairs (DVA) Homes Division to regularly inspect the rooms of residents for Health and Safety, Environmental, Housekeeping and Plant Operations issues monthly and if there is reasonable concern for Health and Safety of the residents an immediate inspection is conducted per interview with the Health and Safety Officer of the facility today at around 12:15 PM.

Regarding the allegation that Facility staff refused to provide resident with food, it was alleged that a staff member had refused to serve resident dinner in the dining room. LPA Harriel's interview with Resident #2 (R2) on 07/18/19 at around 4:00 PM revealed that Staff #1 (S1) walk passed R2 during dinner. LPA's interview with Staff #2 (S2) today at 1:15 PM, however, revealed that R2 filed a complaint against S1 of being racist and was advised to stay away from R2 by S1's supervisor to avoid aggravation. Further, S1 got another staff to serve R2 during that incident.

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: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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