197607726-12-14-2022-31-AS-ERIS-CM4RHP-20221214120241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607726
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:03:34 PM

Document Has Been Signed on 12/14/2022 12:03 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:	ELVIE ANCHETA		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	60	CENSUS: 48	DATE:	12/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elvie Ancheta		TIME COMPLETED:	12:15 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	At 9:45 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz conducted an unannounced Required Annual/Infection Control inspection at this facility. LPAs were greeted by staff and later met with Administrator Elvie Ancheta and Seema Misra. LPA reviewed the Mitigation Plan approved 03/22/2021. The inspection tool was used to complete the visit. At 10:30 a.m. LPA with staff Seema Misra began a physical plant tour of the facility and the following was observed: Infection control: Upon arrival, staff #1 (S1) who was wearing a mask took LPA’s temperature, was asked to sign-in the visitor’s log and was asked infection control questions. Proper signs were observed posted outside the facility and inside along the hallway. Hand sanitizer was also observed. LPA observed sufficient PPE supplies for residents and staff. Staff Seema stated there are two designated resident entrances and a separate staff entrance, all of which consists of designated staff screening visitors and staff for infection control protocols. Staff Agnes stated extra PPE is stored in an on site warehouse. Medications are in a centrally stored and are kept locked in two nurse stations. Resident rooms: There are 36 bedrooms designated for resident use. Twelve (12) out of the thirty six (36) are single and the other twenty four (24) are shared rooms. All resident rooms include a private bathroom. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens. Smoke detectors/carbon monoxide: Smoke and carbon monoxide detectors were located throughout the facility. Fire drills were last conducted on 08/01/2022, 09/21/2022, 09/28/2022 for different shifts. Fire drill consists of activating fire alarms. Fire extinguishers located through out the facility were all last serviced on 03/07/2022

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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: 12/14/2022

NARRATIVE

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Food Inspection: LPA observed there to be sufficient stock of 7-day non-perishable foods and 2-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. There are two designated snack rooms throughout the facility that are maintained open and have refrigerators for residents use opened 24/7.

Bathrooms: At 10:47 a.m. the hot water temperature measured at 118.8 F. LPA observed bathrooms were well lit, clean, had grab bars, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels.

Common area: Common area consists of library, dining hall, muti purpose room and two activity rooms. All areas were well lit and appropriate furniture was observed. Furniture appeared to be clean and in good repair.
Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor seating, with various covered shaded areas for clients. There are no bodies of water. No deficiencies observed at this time.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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