197607726-12-14-2022-31-AS-NGID-CMDTKR-20221223134819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:07:31 PM

Unsubstantiated

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
09/16/2022 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220916143013

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
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elvie Ancheta		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility staff are emotionally abusing resident while in care.
Facility staff are retaliating against resident for making complaints.

INVESTIGATION FINDINGS:

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On 12/14/2022 Licensing Program Analysts (LPAs) Melissa Ruiz and Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by the security staff, and later met with the Administrator, Elvie Ancheta and Seema Misra. LPAs conducted an entrance interview and explained the purpose of the visit.

It was alleged that facility staff are emotionally abusing a resident while in care and that facility staff are retaliating against a resident for making complaints. To investigate these allegations, LPA interviewed the facility Administrator, facility staff, R1’s physician, and one resident (R2). LPA also conducted record review and obtained documents related to this investigation. According to the Administrator and facility staff, the resident in question (R1) stopped taking their medication and started having a change in condition and behavior.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220916143013

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: 12/14/2022

NARRATIVE

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LPA interviewed R2 on 9/23/2022. According to R2, R2 thinks that R1 had a change in condition and became “manic”. R2 also stated that R1 would speak up on R2’s behalf to staff for issues related to food, privacy, etc. However, R2 said that they do not believe that staff retaliated against R1, but that R1 was upset and blamed staff for requesting additional medical help for R1. According to the Administrator, on 9/20/2022, due to various behavioral incidents, staff called 988 – Suicide and Crisis Lifeline, and R1 was upset that they called “911”. Afterwards, there was a meeting set up with R1, facility staff, R1’s physician, and R2 was asked to join for moral support. In this meeting, R1 had agreed to be admitted to a hospital to seek medical help. During that meeting, R1 became agitated and barricaded themselves with facility staff for hours. Afterwards, R1 was placed on a 51/50 hold. Administrator denied emotionally abusing R1, or retaliating, but due to the sequence of events, R1 verbally voiced these allegations to the Administrator. Facility staff and R1’s physician stated that they have not emotionally abused or retaliated against R1, nor do they believe that any other staff including the Administrator has. On the contrary, they stated facility staff has attempted to help R1 get better and seek the help they need. Record review revealed that R1 had refused various medications throughout the month of September. R1’s progress notes show that R1 had various behavioral episodes throughout the month of September as well.

Due to interviews and record review, the allegations mentioned above are unsubstantiated at this time. No deficiencies issued, report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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

LIC9099 (FAS) - (06/04)

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