336413271-5-21-2025-18-AS-RSTS-DH6NN9-20250530103622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336413271
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:35:51 PM

Unsubstantiated

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
12/03/2024 and conducted by Evaluator Seo Jeon

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20241203155436

FACILITY NAME:	DESERT COTTAGE		FACILITY NUMBER:	336413271
ADMINISTRATOR:	ELIZABETH HENGSTLER		FACILITY TYPE:	740
ADDRESS:	83-617 HIMILAYA DRIVE		TELEPHONE:	(760) 342-7767
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2025
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Destiny Villalta, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are restraining residents
Staff are proving THC drinks/Protein powder to residents without a Physicians order
Staff are restricting visiting hours
Residents are charged for services not rendered
Residents moved to other facilities without consent
Residents are left unattended
Staff put up bed rails without physicians orders

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit for additional investigation and met with Destiny Villalta, Administrator. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files, and records, and obtained supporting documentation to aid in determining the findings of the noted allegations.

On December 3, 2024, Community Care Licensing (CCLD) received a complaint report with the following allegations.

It was alleged staff are restraining residents. LPA toured interior and exterior of the facility. LPA did not observe anything used to physically restrain residents. LPA interviewed (3) three residents, but no one confirmed they had experienced any form of restraint. LPA interviewed two (2) staff members, but both denied using any form of restraints on residents.
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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 2

Control Number 18-AS-20241203155436

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: 05/21/2025

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
26
27
28
29
30
31
32

It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. LPA toured interior and exterior of the facility. LPA did not observe any THC drinks in the facility. LPA observed supplementary drinks with protein in the pantry. 3 out 5 residents consume the protein drinks. LPA observed doctor’s orders for the protein drinks in those three (3) residents files.

It was alleged staff are restricting visiting hours. LPA observed the facility visiting policy outlining visiting hours next to the front door. Staff members confirmed visitors who come after hours will be allowed entry after calling the licensee. Staff members stated they have never turned away any visitors.

It was alleged residents are charged for services not rendered. LPA’s interview with the administrator revealed the only extra charge to the resident’s account will be the incontinence supplies. LPA’s review of the admission agreement revealed each resident receives basic care services and their charges are aligned with the basic level services.

It was alleged residents moved to other facilities without consent. LPA’s interview with the administrator revealed residents sometimes visit another facility owned by the same licensee when there are community activities. LPA observed three (3) residents receiving haircuts, and one of the residents returned to their home facility after their haircut.

It was alleged residents are left unattended. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA reviewed the staff schedule and S1’s live-in employment agreement. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended.

It was alleged staff put up bed rails without physician’s orders. LPA observed 1 of 5 residents with full bed rails. LPA observed 3 of 5 residents have half bed rails. LPA’s file review revealed resident #1 has doctor’s order for full bed rails, and residents #2, #3, and #4 also have doctor’s orders for half bed rails.

Based on records review, resident interviews, and staff interviews, above allegations are Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where a copy of this report was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2