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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 01:42:45 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
04/08/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240408110606
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 are placing restraint vests on residents 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, residents, and relevant parties and reviews of records.

On 04-08-2024, Community Care Licensing (The Department) received a complaint report with the following allegation.

It was alleged that staff are placing restraint vests on residents in care. Information received indicated that staff place weighted vests on residents when they go to sleep, so that the residents cannot get out of bed. LPA conducted interviews with Relevant Party #1 (RP1), Relevant Party #2 (RP2), and Relevant Party #3 (RP3), all of whom confirmed the weighted vests being placed on residents in care.
Continued on LIC9099-C....
Substantiated
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 6
Control Number 18-AS-20240408110606
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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RP1 stated they took photos of two (2) residents wearing weighted vests. RP2 stated they held the weighted vest at the facility. RP3 stated they saw Resident #5 wearing a weighted vest at the facility. LPA observed two (2) photos of residents wearing weighted vests. Based on records review and interviews conducted, this allegation is substantiated.

Based on interviews conducted and records reviews, 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 and discussed, along with a copy of LIC9099-D, and Appeal Rights were 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 6
Control Number 18-AS-20240408110606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2025
Section Cited
CCR
80072(a)(3)
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Personal Rights, (a) Except for children’s residential facilities, each client shall have personal rights, (3) To be free from corporal or unusual punishment, infliction of pain,....

This requirement was not being met as evidenced by:
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Licensee will ensure staff will adhere to personal rights regulation.
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Based on interviews conducted with relevant parties and records review, staff placed weighted vests on residents in care. This posed an immediated health, safety and personal rights risk to the 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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/08/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240408110606

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 did not prevent a resident from falling.
Staff hit a resident in care.
Resident sustained an unexplained injury while in care.
Facility did not report incidents to resident's responsible party.
Staff over medicated a resident in care.
Staff left residents unsupervised at the facility.
Staff are chemically restraining residents in care.
Staff are using bedrails to restrain residents in care.
Food services are inadequate.
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 the purpose of the LPA's visit. The Department investigation involved interviews with staff, residents, and relevant parties, and reviews of records.

On 04-08-2024, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff did not prevent a resident from falling. Information received indicated Resident #1 (R1) had two (2) falls and sustained bumps on the back of their head as a result of the falls. LPA’s interview with Staff #1 (S1) revealed R1 had a fall incident on March 4, 2024, and was sent to a hospital by ambulance. According to a relevant party, R1 had another fall incident on March 25, 2024, and sustained another bump on the back of their head.

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: 4 of 6
Control Number 18-AS-20240408110606
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 conducted an interview with S1 who denied knowledge of R1’s second fall incident on March 25, 2024. LPA’s record review revealed the Department received R1’s March 4, 2024, fall incident, but not the second fall incident occurred on March 25, 2024. LPA’s file review also revealed R1 was not assessed as a fall risk nor required one on one care. LPA’s file review revealed staff did not re-assess R1 after the fall incident. LPA conducted interviews with three (3) residents, all of whom denied having any fall incidents. LPA conducted interviews with three other (3) staff members, all of whom denied witnessing any resident's falls. Based on file review and interviews conducted, this allegation is unsubstantiated.

It was alleged staff hit a resident in care. According to the information received, R1 stated they were hit in the back of their head by a staff member and fell forward to the ground. R1 did not state what they were hit in the back of their head with. LPA conducted interviews with four (4) staff members, all of whom denied hitting a resident. LPA conducted interviews with three (3) relevant parties, all of whom denied witnessing staff hitting a resident. Additionally, LPA conducted interviews with three (3) residents, all of whom denied experiencing or witnessing staff hitting a resident. Based on interviews conducted, this allegation is unsubstantiated.

It was alleged resident sustained an unexplained injury while in care. Information received indicated that R1 was observed with multiple bruises on their arms. LPA conducted interviews with four (4) staff members, all of whom denied having any knowledge of the unexplained bruises on R1’s arms. LPA conducted interviews with three (3) relevant parties, all of whom denied having any knowledge of the bruises on R1’s arms. Additionally, LPA conducted interviews with three (3) residents, but none had any knowledge of bruises on any residents. Based on interviews conducted and due to lack of any evidence, this allegation is unsubstantiated.

It was alleged facility did not report incidents to resident’s responsible party. Information received indicated that R1 had a lump in the back of their head, and R1’s responsible party was not notified. LPA conducted a review of the Department’s incident log and found that staff reported R1’s incident on March 8, 2024. LPA conducted an interview with the Administrator who stated the incident was reported to all parties, and R1 was transported to a hospital in an ambulance after receiving OK from R1’s responsible party. R1 returned to the facility on the same day by their responsible party. Based on records review and interviews conducted, 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)
Page: 5 of 6
Control Number 18-AS-20240408110606
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 staff over medicated a resident in care. According to the information received, R1 was observed to be slow with their speech and not as clear with their thinking. LPA’s records review revealed that R1 was on psychiatric medication. LPA conducted an interview with the Administrator who stated all medications have been dispensed according to the prescriptions. LPA conducted interviews with three other (3) staff members, all of whom denied having any knowledge of residents being over medicated. LPA conducted interviews with three (3) residents, all of whom denied being over medicated. Based on records review and interviews conducted, this allegation is unsubstantiated.

It was alleged that staff left residents unsupervised at the facility. Information received indicated S1 leaves the residents unattended at the facility. LPA conducted interview with S1 who denied leaving the residents unattended. LPA conducted interviews with three other (3) staff members, all of whom denied leaving the residents unattended. LPA conducted interviews with three (3) residents, all of whom stated staff members are always present. LPA’s review of staff schedules confirmed the above statements. Based on records review and interviews conducted, this allegation is unsubstantiated.

It was alleged that staff are chemically restraining residents in care. Information received indicated that staff served THC drinks to residents to keep them sedated. LPA conducted interviews with four (4) staff members, all of whom stated THC drinks were provided to residents only with physician orders. LPA’s records review revealed that three (3) residents have doctor’s orders for cannabis or THC drinks. Based on records review and interviews conducted, this allegation is unsubstantiated.

It was alleged staff are using bedrails to restrain residents in care. LPA conducted interviews with four (4) staff members, all of whom stated bedrails were used only with physician orders. LPA’s resident file review confirmed the staff’s statement about the bedrails. Based on records review and interviews conducted, this allegation is unsubstantiated.

It was alleged that food services are inadequate. LPA conducted interviews with four (4) staff members, all of whom stated staff have provided more than enough food services to the residents in care. LPA conducted interviews with three (3) residents, all of whom stated staff have provided three (3) meals per day. Based on interviews conducted, 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 where 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: 6 of 6