336423672-9-30-2025-18-AS-RSTS-DMK24S-20251017170421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423672
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:52:07 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
12/10/2024 and conducted by Evaluator Seo Jeon

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20241210103507

FACILITY NAME:	DESERT COTTAGE II		FACILITY NUMBER:	336423672
ADMINISTRATOR:	ELIZABETH HENGSTLER		FACILITY TYPE:	740
ADDRESS:	83-421 MATADOR COURT		TELEPHONE:	(760) 342-7767
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY:	6	CENSUS: 3	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Elizabeth Hengstler, Licensee		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility staff did not meet resident’s incontinence care needs
Facility staff withheld food from resident
Facility staff handled resident in a rough manner
Facility staff spoke inappropriately to resident
Facility staff restricted resident's ability to communicate with family

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 allegations. LPA met with Elizabeth Hengstler, Licensee, and informed them of purpose of the LPA's visit. The Department investigation involved interviews with staff and records review.

On 12-10-2024, Community Care Licensing (The Department) received a complaint report with the following allegations.

It was alleged that facility staff did not meet resident’s incontinence care needs. According to the information received, Resident #1 (R1) did not receive incontinence care from staff for 3 days in December 2024. LPA conducted interviews with four (4) staff members, three (3) of whom stated staff have provided incontinence care to residents every two (2) hours or as necessary.

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)

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Control Number 18-AS-20241210103507

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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Additionally, LPA conducted interviews with three (3) residents, two (2) of whom stated staff have provided incontinence care in timely manner. LPA conducted an interview in December 2024 with R1 who stated they did not receive incontinence care from the staff. However, LPA conducted another interview in August 2025 with R1 who then stated they received timely incontinence care from the staff. This allegation is unsubstantiated.

It was alleged that facility staff withheld food from resident. According to the information received, R1 did not receive meals for four (4) days. LPA conducted interviews with four (4) staff members, all of whom denied withholding food from residents. Staff #1 (S1) stated that R1 sometimes has gone through “fasting” for unknown purpose. LPA’s previous interview with R1 regarding a separate complaint report in October 2024 corroborated the S1’s statement that R1 sometimes would fast. LPA conducted interviews with three (3) residents, all of whom denied staff withholding food from them. LPA conducted follow-up interview in August 2025 with R1 who stated they received three (3) meals per day and denied experiencing staff withholding food from residents. This allegation is unsubstantiated.

It was alleged that facility staff handled resident in a rough manner. According to the information received, S1 was physically rough with R1 when moving them. LPA conducted interviews with four (4) staff members, three (3) of whom denied rough handling with residents. LPA conducted interviews with three (3) residents, all of whom denied staff’s rough handling. LPA conducted an interview in December 2024 with R1 who stated they were handled in rough manner by S1. However, LPA conducted follow-up interview in August 2025 with R1 who now denied rough handling from any staff member. This allegation is unsubstantiated.

It was alleged that facility staff spoke inappropriately to resident. According to the information received, S1 told R1 that they had no rights because they lived in a group home. LPA conducted interviews with four (4) staff members, all of whom denied speaking inappropriately to residents. Interviews with three (3) residents also revealed no reports of inappropriate language from staff. LPA conducted follow-up interview in August 2025 with R1 who now denied staff speaking inappropriately to residents. This allegation is unsubstantiated.

Continued on LIC9099-C....

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)

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Control Number 18-AS-20241210103507

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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It was alleged that facility staff restricted resident’s ability to communicate with family. According to the information received, staff took R1’s phone away. LPA conducted interviews with four (4) staff members, all of whom denied restricting resident’s communication or taking away resident’s phone. According to the facility Administrator, R1’s responsible person removed the phone because R1 could not use it due to R1’s health condition, physically preventing them from using the phone. LPA observed R1 could not hold or dial a phone due to issues with their hands. LPA’s interviews with three (3) residents confirmed staff did not restrict communication with family or others outside the facility. This allegation 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)

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