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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413271
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:31:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220330113756
FACILITY NAME:DESERT COTTAGEFACILITY NUMBER:
336413271
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-617 HIMILAYA DRIVETELEPHONE:
(760) 342-7767
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 6DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Elizabeth HengstlerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained an unwitnessed fall resulting in a fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to deliver investigation findings for the above listed allegation. LPA met with Licensee, Elizabeth Hengstler, who was informed of the purpose of the visit.

The investigation consisted of Department conducted record reviews and interviews. The records reviewed include monthly care plans for Resident 1 (R1), the admission agreement for R1, the needs and service plan for R1, medical records for R1 and the facility Program Plan. Interviews were conducted with 3 residents, one of which was the victim, 2 family members of R1, the Ombudsman, 3 facility staff members and the facility Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20220330113756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DESERT COTTAGE
FACILITY NUMBER: 336413271
VISIT DATE: 01/09/2025
NARRATIVE
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Hospital medical records document on 03/09/2022 R1 was transported to a local hospital and was diagnosed with an angulated overriding right intertrochanteric fracture. Staff provided inconsistent accounts of the incident surrounding R1’s fall. The licensee reported live-in night shift staff, Staff 1 (S1), sleeps throughout the night. S1 will check on residents at 2300 hours and then sleeps until morning when residents start to awaken between 0630 and 0700 hours. S1 corroborated this and indicated they do not check on residents unless summoned by residents. Staff interviews revealed AM staff arrive at 0700 hours. Staff 2 (S2) reported finding R1 at 0700 hours on 03/09/2022 on the floor of R1’s bedroom. S2 was unaware of how long R1 was on the floor before being found. The licensee corroborated being called to R1’s bedroom by S2 at 0700 hours and finding R1 on the floor. S1 reported they slept at the facility but were not “on duty” the day prior and the day of the incident. There were no other staff present during the night shift. S1 reported even when they are off duty they would listen for residents and assist them if needed. S1 reported they did not observe or hear anything unusual the night of the incident.

Staff consistently reported R1 required assistance of wheelchair and walker when ambulating. However, staff keeps these devices out of eyesight, so R1 is not tempted to access the devices independently. During a visit by Department staff on 06/13/2022, the Department staff observed R1’s wheelchair to be placed out of sight of R1 approximately 10 feet away.

The Desert Cottage Program Plan documents, “at least two caregivers will be available to the residents at all times.” Facility Admission Agreement for R1, dated 05/17/2021; documents R1 is receiving Level 2 services which are for residents that rely on the facility for extensive assistance with personal activities of daily living and includes residents who are a fall risk or have declining mobility. Basic services in the admission agreement include continuous care and supervision.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 18-AS-20220330113756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT COTTAGE
FACILITY NUMBER: 336413271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
01/10/2025
Section Cited
CCR
87101(c)(3)
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(c) (3) "Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: This requirement was not met as evidenced by:
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The Licensee agrees to submit an attestation that caregivers will be available to the residents as specified by the Program Plan.
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Based on the Department’s records review and interviews conducted the Licensee did not ensure sufficient staffing levels were provided as specified by the Program Plan and Admission Agreement. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20220330113756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DESERT COTTAGE
FACILITY NUMBER: 336413271
VISIT DATE: 01/09/2025
NARRATIVE
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Based on the interviews conducted and the records reviewed, the facility was not sufficiently staffed to meet the basic service requirements of the Admission Agreement or the Program Plan and therefore the allegation of Neglect/Lack of Care and Supervision is SUBSTANTIATITED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR). A lack of care and supervision resulted in R1 suffering a fall with serious bodily injury therefore, an immediate $500 civil penalty is being assessed on this day in accordance with Health and Safety Code Section 1569.49(e). The determination of additional civil penalties are under review, and a determination is pending by the Department.

An exit interview was conducted and a copy of this report, appeal rights and a confidential names list were provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4