197607726-12-16-2024-31-AS-ERIS-DC237G-20241216165955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607726
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:00:10 PM

Document Has Been Signed on 12/16/2024 05:00 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/ DIRECTOR:	EDINA LEMUS		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 0	CENSUS: 39	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Edina Lemus		TIME VISIT/ INSPECTION 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	On 12/16/2024 at approximately 10:30 a.m. Licensing Program Analyst (LPA) Evelin Rios, conducted an Annual Required visit and inspection of the facility. Upon entry LPA was asked to sign in by a security guard at reception. Facility utilizes one main entrance for visitors and has different entry and exits for residents and staff through out the facility. LPA met with Administrator Edina Lemus, and explained the reason for the visit. LPA requested a copy of the resident roster, personnel report, and facility's policy other than what was submitted during the application process. LPA along with the administrator and later with Agnieszka Sibbitt, the Supervisory Registered Nurse conducted a physical plant tour at approximately 10:50 a.m., and the following was observed: By the main entrance and through out the facility LPA observed appropriate postings such as, resident's rights, Rights of Resident Council, the facility's activity calendar and menu. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food were in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separated from food preparation area. LPA discussed food delivery, meal planning and overall food monitoring with the Food Manager on today's visit. The CA Department of Forestry and Fire Protection conduct an annual inspection on 06/10/2024. LPA requires more time to review CAL FIRE's report. Report states deficiencies were noted and require corrective action. Facility provided to LPA, a fire system smoke detector inspection conducted by Champions Fire System Inc certifying no defects for devises. It appears all fire extinguishers were last serviced on December 15, 2023. Common Areas: These includes the activity room, gym, lounge, snack rooms, and dining area. (Continue to LIC809)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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: 12/16/2024

NARRATIVE

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The furniture is in good repair. Hallways and passageways are free of obstruction.

Surrounding Grounds: Entry/exits and hallways were free of obstruction. There is a court yard accessible to residents with appropriate outdoor furniture. The outdoor area was free of hazards. There are no bodies of water.

LPA reviewed facility's Emergency Disaster Plan (LIC610E), Emergency Operation Plan, Fire and Safety Inspection (STD850) for the modular unit, Fire Drills, Liability Certification and Bond and speciality insurance. At approximately 2:10 p.m. LPA and the administrator discussed the PolicyTech and whether the administrator before had submitted the information to CCL. Administrator could not definitely say if one was provided but confirmed any updates or changes to PolicyTech have not been submitted to CCL.

Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff files, resident records, or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection.

Deficiency Cited and cleared on todays visit (refer to LIC809-D). Exit interview conducted. Appeal Rights Provided. Copy of report signed and provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2024 05:00 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited. The facility uses PolicyTech, which significantly impacts services to residents, but failed to provide a copy and all updated or new policies to CCL, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Facility provided LPA with a title list of policies on PolicyTech and all policies the facility adheres to on PolicyTech via email today. Deficiency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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