197607726-9-5-2025-31-AS-MGFS-DXJVED-20260902162209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607726
Report Date: 09/05/2025
Date Signed: 09/05/2025 05:24:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250819093514

FACILITY NAME:	WILLIAM J. "PETE" KNIGHT VETERANS HOME-LANCASTER		FACILITY NUMBER:	197607726
ADMINISTRATOR:	EDINA LEMUS		FACILITY TYPE:	740
ADDRESS:	45221 30TH STREET WEST		TELEPHONE:	(661) 974-7035
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	60	CENSUS: 34	DATE:	09/05/2025
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Edina Lemus / Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff are not following a physician's orders.

INVESTIGATION FINDINGS:

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On 09/05/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by staff and asked to sign in. LPA then met with the Administrator Edina Lemus. LPA explained the purpose of the visit.

Allegation: Staff are not following a physician's orders. Regarding the allegation, it was reported that staff did not administer Resident (R1)'s PRN (as-needed) medication at the time it was requested, and that R1's oxygen tank was removed by staff. To investigate the allegation LPA Rios conducted an initail visit on 08/25/2025. During the visit, at approximately 10:39 a.m., LPA requested documentation including, but not limited to, the resident roster, personnel report, R1's physician’s report, centrally stored medication records, and Inter-disciplinary Team (IDT) meeting notes. At approximately 10:56 a.m., LPA Rios conducted an interview with the Supervising Registered Nurse, Takira Florence. From approximately 12:30 p.m. to 2:00 p.m., LPA completed a physical plant tour of the facility and interviewed five (05) residents. At 3:19 p.m., LPA interviewed an additional staff member. (Continue to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

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-20250819093514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/05/2025

NARRATIVE

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(Continued from LIC9099) During today's subsequent visit, at approximately 1:33 p.m., LPA interviewed Dr. Mariam Schwartz, a licensed Physician and Surgeon. Although Dr. Schwartz is not R1’s primary physician, she indicated she is part of the IDT that ensures alignment in care for R1. LPA also briefly met with Supervising Registered Nurse and staff member to clarify information provided during the previous interview conducted on 08/25/2025.

LPA’s interview with R1 on 08/25/2025 revealed that the resident affirmed the allegation. According to R1, there were two separate occasions that staff held R1's medication while it was being centrally stored by the facility citing a written order to delay administration following prior opioid use. R1 was only able to provide a date for one of the two incidents. R1 did not believe their was such an order. Additionally, R1 affirmed her oxygen tank was removed from her room, with the facility citing R1 did not have a prescription order for the use of oxygen. According to R1 they have a letter from their doctor confirming the use and need of the oxygen. LPA obtained a copy of the letter. LPA confirmed with R1 that they were reassessed and now have control of all their PRN medication. Interview with four (04) out five (05) residents on 08/25/2025 corroborate not having issues regarding their medication.

An interview with the staff member on 08/25/2025 confirmed that on one occasion, PRN medication was delayed because R1 had recently taken a dose of opioid PRN medication for pain. The staff member recalled the incident may have happened in August 2025. Both the staff member and Dr. Schwartz indicated—though not verbatim—that delaying medication in such circumstances is a safety precaution intended to monitor the resident’s response. According to Dr. Schwartz and the Supervising Registered Nurse, the medication in question is in pill form and requires time to dissolve and take effect.

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Continued to LIC9099-C

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250819093514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/05/2025

NARRATIVE

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LPA’s review of R1’s centrally stored medication records, medication administration record (MAR) for June and July 2025, and medication profile for August 2025 revealed that the medication order was updated in July to include instructions to hold PRN opioid medication for four hours if a prior dose of opiod medication had been administered. This instruction was not present in the June documentation. According to R1's physician's report their medication became centrally stored on 06/10/2025.

LPA's review of R1's letter confirmed R1's use of oxygen. However it was not a prescription and no current prescription or letter has been provide stating the medical reason for the use of oxygen. LPA's review of Inter-disciplinary Team (IDT) meeting notes, Dr.Schwartz interview and clinical notes corroborate that R1's physicians state there is no indication for the use of oxygen. R1's physicians will also not provide a prescription. Interview with Administrator and Supervising Registered Nurse on 08/25/2025 confirmed the oxygen supplement was removed from R1's room and placed in facility storage for R1. Based on record reviews indicating no documented medical need for oxygen, confirmation of medication hold orders, and corroborating staff interviews, this allegation is deemed unsubstantiated at this time.

No health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of the report was provided.

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SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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