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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413271
Report Date: 12/03/2025
Date Signed: 12/03/2025 11:38:12 AM

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 COTTAGEFACILITY NUMBER:
336413271
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-617 HIMILAYA DRIVETELEPHONE:
(760) 342-7767
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 6DATE:
12/03/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Elizabeth Hengstler, LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff are restraining residents
Staff are providing THC drinks/Protein powder to residents without a Physicians order
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:
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This is an amended complaint investigation report of the original report that was delivered on 05-21-2025. This amended report is created due to being longer than the original report.

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to deliver amended complaint investigation report that was delivered on 05-21-2025 and met with Elizabeth Hengstler, Licensee. 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.
Continued on LIC9099-C.....

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
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 7
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: 12/03/2025
NARRATIVE
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It was alleged staff are restraining residents. According to the information received, staff are placing weighted vests on residents to keep them immobile. LPA toured and thoroughly searched interior and exterior of the facility but was unable to locate any weighted vest or anything like it. LPA did not observe anything used to physically restrain residents. LPA conducted interviews with five (5) residents, but LPA determined that two (2) out of five (5) residents were unable to be interviewed due to their cognitive condition per attempted interviews. Interviews with the remaining three (3) residents revealed that they have never seen weighted vests or experienced any form of restraint by staff. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied seeing residents wearing weighted vests or any form of restraint. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied ever using any form of restraint or weighted vests on residents. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are restraining residents. This allegation is unsubstantiated.

It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. According to the information received, staff are serving THC (Tetrahydrocannabinol) drinks to keep residents sedated and are giving protein drinks without doctor’s order. LPA conducted a tour of interior and exterior of the facility but did not observe any THC drinks or protein drinks. LPA observed nutritional supplements in both liquid and powder forms in the facility kitchen pantry. LPA’s record review revealed that three (3) out of five (5) residents had doctors’ orders for nutritional supplements. LPA conducted interviews with five (5) residents, but none of them knew if they consume nutritional supplements. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, none of whom knew if the residents consumed THC drinks or nutritional supplements. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied serving THC and protein drinks to residents without doctors’ orders. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are providing THC drinks/protein powder to residents without a physician’s order. This allegation is unsubstantiated.

It was alleged residents are charged for services not rendered. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied being charged for services or goods not provided.

Continued on LIC9099-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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: 12/03/2025
NARRATIVE
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LPA conducted an interview with the Administrator who stated that the only extra charges would be for services such as haircut(s), podiatry services, or incontinence care 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. LPA conducted interviews with three (3) staff members, all of whom denied having any knowledge of fees charged to the residents. Based on interviews conducted and file review, there is insufficient evidence to support the allegation that residents are charged for services not rendered. This allegation is unsubstantiated.

It was alleged residents moved to other facilities without consent. According to the information received, the Administrator moves the residents around between the two facilities owned by the same Licensee. LPA conducted interviews with five (5) residents, but LPA determined that two (2) out of five (5) residents were unable to be interviewed due to their cognitive condition per attempted interviews. Interviews with the remaining three (3) residents revealed that they have never been moved to another facility for any kind of activities. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied any knowledge of residents being moved to another facility for daytime activities. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied moving the residents to another facility for activities. Based on interviews conducted, there is insufficient evidence to support the allegation that residents moved to other facilities without consent is unsubstantiated.

It was alleged residents are left unattended. According to the information received, the Administrator frequently leaves the residents alone at night. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA’s review of staff schedule and S1’s live-in employment agreement corroborated the staff members’ statements. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended. LPA conducted interviews with three (3) residents, all of whom stated there are staff members present throughout the day and night. LPA conducted three (3) residents’ responsible persons, all of whom stated there were staff members present whenever they visited. LPA conducted night-time visit and observed staff members were present at the facility. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that residents are left unattended. This allegation is unsubstantiated.

Continued on LIC9099-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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: 12/03/2025
NARRATIVE
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It was alleged staff put up bed rails without physician’s orders. LPA observed one (1) of five (5) residents with full bed rails. LPA observed three (3) of five (5) residents have half bed rails. LPA’s file review revealed Resident #1 had doctor’s order for full bed rails, and Residents #2, #3, and #4 also had doctor’s orders for half bed rails. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that staff put up bed rails without physician’s orders. This allegation is unsubstantiated.

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: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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 COTTAGEFACILITY NUMBER:
336413271
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-617 HIMILAYA DRIVETELEPHONE:
(760) 342-7767
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 6DATE:
12/03/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Elizabeth Hengstler, LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
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Staff are restricting visiting hours
INVESTIGATION FINDINGS:
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This is an amended complaint investigation report of the original report that was delivered on 05-21-2025. This amended report is created due to being longer than the original report.

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to deliver amended complaint investigation report that was delivered on 05-21-2025 and met with Elizabeth Hengstler, Licensee. 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.

Continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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: 12/03/2025
NARRATIVE
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It was alleged staff are restricting visiting hours. According to the information received, there is a visiting hour posted at the facility door, and visitors must call before visiting. During the tour of the facility, LPA observed a sign at the facility door showing visiting hours of 10:00 AM to 6:00 PM. The sign also showed requirement for visitors to obtain approval for visitation during mealtimes. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied experiencing any restriction with visitation. However, the three (3) responsible persons stated they usually call the Licensee if they are visiting outside the posted visiting hours. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom stated no visitors have been denied entry to the facility outside of the visiting hours if the visitors get approval from the Licensee. Based on the interviews conducted and observation, there is sufficient evidence to support the allegation that staff are restricting visiting hours. This allegation is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099C, LIC9099D, and Appeal Rights were provided.

***LPA Seo Jeon conducted subsequent visit to deliver amended LIC9099-D with new plan of correction.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2025
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities.
(a) Residents in all residential care facilities for the elderly shall have... (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to...during reasonable hours and without prior notice
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Licensee will remove the visiting hour sign and send proof of having personal rights training by the POC due date.
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Based on LPA's observation, the Licensee posted visiting hours at the entrance of the facility which poses potential personal rights violation to 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: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7