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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423672
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:50:05 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
12/06/2023 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231206152231
FACILITY NAME:DESERT COTTAGE IIFACILITY NUMBER:
336423672
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-421 MATADOR COURTTELEPHONE:
(760) 342-7767
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 3DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Elizabeth Hengstler, LicenseeTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff physically abused resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Elizabeth Hengstler, Licensee, and informed them of the purpose of the LPA’s visit. The Department investigation involved interviews with staff and records review.

On 12-06-2023, Community Care Licensing (The Department) received a complaint report with the following allegation.

It was alleged that staff physically abused resident in care. Information received indicated Resident #1 (R1) was physically abused by Staff #1 (S1). According to a relevant party, R1 was observed with bruises on the right side of their body, head, and face. R1 was also observed with cuts on their forehead. Relevant party informed the Licensee regarding the alleged physical abuse by S1, but the Licensee denied knowledge of any type of physical abuse going on at the time.
Continued on LIC9099-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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-20231206152231
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 II
FACILITY NUMBER: 336423672
VISIT DATE: 09/30/2025
NARRATIVE
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LPA’s file review indicated R1 was admitted to the facility in April 2023, placed under hospice care in August 2023, and moved out on 12-06-2023 to another facility. R1 passed away in September 2024. R1 was the only resident at the time of the alleged abuse.

During the investigation, LPA interviewed R1’s relevant party, who relayed a disturbing account allegedly shared by R1 that S1 had dragged R1 across the floor from the bathroom to the bed, forcefully thrown R1 onto the bed, and slapped R1 multiple times after a fall near the toilet.

LPA attempted to interview two (2) staff members from the hospice agency, but it was unsuccessful. R1 had a roommate, but that person passed away in October 2023, so no interview was conducted. LPA conducted interview with two (2) staff members including S1, both of whom denied the alleged physical abuse took place. LPA learned there was a police report generated from an incident that occurred on 11-25-2023 related to R1. LPA obtained and reviewed the police report from Indio Police Department. The information obtained from the police report did not contain supportive evidence to corroborate the allegation.

Based on records review and interviews conducted, the allegation that staff physically abused resident in care is 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, and a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2