William J. Pete Knight Veterans Home-lancaster

On 08/13/2025, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility for an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Assistant Administrator Wendi Doyon and Administrator Edina Lemus. The purpose of the visit was explained, and an entrance interview was conducted. LPA Rios conducted a physical plant tour of the facility and did not observe any immediate health or safety concerns. Allegation:Residents are not allowed privacy. Regarding the allegation, it was reported that residents are not accorded privacy during sensitive conversations with Veterans Service Officer (VSO). LPA’s review of the CalVet website found that VSOs work directly with individual veterans and their families to ensure veterans receive benefits they earned through their service. (Cont. to LIC9099-C) SubstantiatedRead the full finding— CDSS inspection report, August 13, 2025 · control 31-AS-20241211135010

On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Assistant Administrator, Wendi Doyon and later with Administrator Edina Lemus. LPA explained the purpose of the visit. Allegation: Staff is not following food service sanitation practices. Regarding the allegation it was reported that staff used personal cellphones while serving meals and and did not use gloves while preparing food. To investigate the allegation LPA Rios conducted an initial complaint visit on 06/06/25. On 06/06/25 LPA Rios interviewed seven (07) out of thirty-six (36) residents or over 10% of the population. LPA Rios interviewed the administrator and six (06) staff. LPA also obtained and reviewed copies of the facility’s Hand Washing and Food and Nutrition Service Policies, along with documentation of in-service training sessions conducted on 12/02/24, 02Read the full finding— CDSS inspection report, July 9, 2025 · control 31-AS-20250529104617

On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility for an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Administrator Edina Lemus and Assistant Administrator Wendi Doyon and explained the purpose of the visit. An entrance interview was conducted. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On 05/28/2025 LPA Rios interviewed seven (07) residents, the assistant administrator and five (0Read the full finding— CDSS inspection report, July 9, 2025 · control 31-AS-20241211135010

On 06/06/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above for an subsequent complaint visit to deliver findings on the above allegations. LPA was greeted by security and asked to sign in. LPA met with the Administrator, Edina Lemus and Assistant Administrator, Wendi Doyon. LPA explained the purpose of the visit. Entrance interview conducted. LPA requested a copy of the resident roster and personnel report. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents.Read the full finding— CDSS inspection report, June 6, 2025 · control 31-AS-20241211135010

On 05/28/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above for an subsequent complaint visit. LPA was greeted by security and asked to sign in. LPA met with the Assistant Administrator, Wendi Doyon and Executive Secretary I, Nanci Alvarado. LPA explained the purpose of the visit. Entrance interview conducted. LPA requested a copy of the resident roster and personnel report. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On today's visit LPA Rios interRead the full finding— CDSS inspection report, May 28, 2025 · control 31-AS-20241211135010

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. UnsubstantiatedRead the full finding— CDSS inspection report, December 14, 2022 · control 31-AS-20220916143013

At 10:30 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz and Shira Stamps arrived at the facility to conduct an unannounced subsequent complaint visit. LPAs were greeted by security staff and later met with the Administrator, Elvie Ancheta. An entrance interview was conducted, and LPAs explained the purpose of the visit. On 11/13/20, LPA Shanahan conducted an initial 10-day visit. Due to the covid-19 pandemic, the visit was done virtually. During today’s visit, LPAs were able to interview the Administrator, two (2) staff and LPAs attempted to interview a resident who no longer resides at the facility (R1). Additionally, LPAs collected pertinent documents related to this complaint such as R1’s admission agreement, financial status reports, and correspondence letters. It was alleged that the Licensee did not adhere to admissions agreement. (cont. on LIC9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, March 18, 2022 · control 31-AS-20201109154601

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. (coRead the full finding— CDSS inspection report, November 3, 2021 · control 31-AS-20190710105741

Licensing Program Analysts (LPAs) Gary Tan and Eleza Jackson conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Administrator Elvie Ancheta and explained the reason for the visit. LPAs conducted physical plant tour at 10:05 AM, requested facility documents relevant to the investigation at 10:30 AM and interviewed residents and staff between 10:30 AM to 1:00 PM. Regarding the allegation that Facility allowed residents to be in possession of inappropriate items, it was alleged that the facility allows residents to hide a machete, axe, sword, gun, or rifle under their mattress or inside of the closet. LPA Harriel's interview with Resident #1 (R1) on 07/28/19 at around 4:00 PM revealed that R1 did not mention any resident who possessed inappropriate items and R1 just hypothesized it. LPA's interview with the administrator today at 11:00 AM also revealed that she did not receive any report of any resident having anRead the full finding— CDSS inspection report, October 14, 2021 · control 31-AS-20190710105741