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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413271
Report Date: 02/18/2026
Date Signed: 02/18/2026 01:50:07 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
08/25/2025 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20250825133749
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:
02/18/2026
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Elizabeth HengstlerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff caused injuries to a resident
Staff mishandled a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit.
It was alleged that staff caused injuries to a resident. During the investigation, the Licensing Program Analyst (LPA) conducted interviews with staff and reviewed relevant records. Interviews revealed a witness to the incident. Staff #2 (S2) reported observing Staff #1 (S1) hitting Resident #1 (R1) on the face. Interviews revealed S1 reported to work on their day off due to staff call off. While assisting residents, S2 heard R1 scream out and went to check. S2 observed S1 lift and throw R1 onto the bed and then picked R1 back up again and throw R1 into the wheelchair. S2 then observed S1 punch R1 in the face. It was at this point S2 intervened, confronted S1 and contacted the police. Law enforcement arrived and observed bruises on R1’s face.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
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-20250825133749
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: 02/18/2026
NARRATIVE
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Based on the bruising and statements made, S1 was arrested. A review of the police report dated 08-25-25 revealed R1 had an abrasion on right arm, which was about one inch in diameter and had blood on it. The report also states that R1 had a bruise on the left side of face on the cheek that was about one inch in diameter.
It was reported that R1 had minor redness to the right side of the face near cheek and to the bridge of nose. S1 was interviewed and reported while assisting R1, R1 became resistant and dug their nails into S1. S1 then placed R1 on the bed to allow R1 time to calm down. S1 reported they attempted a second time to assist R1 and was again scratched. When S1 placed R1 back down on the bed, for a second time, their left accidentally made contact with R1’s face. S1 reported this was not intentional and occurred while repositioning the resident.

It was alleged that staff mishandled a resident. Concerns were raised that S1 picked up R1 and threw them onto the bed. During the investigation, LPA conducted interviews with three staff members. All interviewed staff stated that while R1 can sometimes be challenging and exhibit aggressive behaviors such as scratching or kicking, they do not believe S1 mishandled R1. Staff described S1 as generally calm and professional when providing care. An interview with S1 revealed that they denied ever mishandling R1 and stated that they always treat residents with dignity and respect. S1 explained that on the day of the incident, they attempted to assist R1 in getting out of bed, but R1 resisted and scratched them. S1 reported that they placed R1 back on the bed to allow time to calm down before attempting again. Although staff interviews generally supported S1’s professionalism, the investigation determined that S1’s own admission of physically placing R1 back on the bed after resistance, combined with the allegation details, supports that inappropriate handling occurred.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20250825133749
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: 02/18/2026
NARRATIVE
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The action of picking up and placing R1 back on the bed, even if intended to calm the resident, constitutes mishandling under Title 22 because it involved physical force without proper de-escalation techniques.

Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report and the 9099-D was provided to Licensee Elizabeth Hengstler. An immediate civil penalty was assessed in the amount of $500
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20250825133749
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: 02/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2026
Section Cited
CCR
87413(a)(2)
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Personnel – Operations
(a) In each facility: (2)Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.
This requirement is not met as evidenced by:
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Licensee agreed to dissociate S1 from facility and send proof of dissociation by POC due date.
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Based on interviews and records review, the licensee did not comply with the section cited above. R1 sustained injuries while 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: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4