336426505-11-20-2025-18-AS-RORN-DP8MK4-20251210084007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426505
Report Date: 11/20/2025
Date Signed: 11/20/2025 02:24:04 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
10/25/2021 and conducted by Evaluator Deborah Lee

COMPLAINT CONTROL NUMBER: 18-AS-20211025095214

FACILITY NAME:	STONEWALL GARDENS ASSISTED LIVING		FACILITY NUMBER:	336426505
ADMINISTRATOR:	BOEDDEKER, ALLEN		FACILITY TYPE:	740
ADDRESS:	2150 N PALM CANYON DR		TELEPHONE:	(760) 548-0970
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	35	CENSUS: 27	DATE:	11/20/2025
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Nisha Henson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Unqualified staff providing medical care.
Staff tested positive for COVID.

INVESTIGATION FINDINGS:

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On November 20, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Nisha Henson and the purpose of the visit was explained.
Investigation consisted of the following:
On October 28, 2021, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. At time of visit, the Department interviewed 5 staff (S1-S5) and 3 residents (R1-R3). The Department obtained the following pertinent documents: Email correspondence (dated: 10/25/21 at 2:44pm), Weekly Care Schedule (dated:10/4/21), Staff training certificates (dated 4/1/21), Staff Roster (no date), Kitchen schedule (no date).
On November 20, 2025, the Department requested and obtain the following documents: Staff roster (dated: 11/2025), Resident Roster (dated: 11/13/25). The department reviewed 4 staff files and interviewed the Residential Care Coordinator/Business Manager (A1).
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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-20211025095214

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: STONEWALL GARDENS ASSISTED LIVING	FACILITY NUMBER: 336426505
	VISIT DATE: 11/20/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Unqualified staff providing medical care.

The detail of the complaint alleges that “staff are asked to do ‘medical tasks’ that they aren’t qualified to do.”

On November 20, 2025, at 1:15 pm, the Department interviewed Nisha Henson, Residential Care Coordinator(A1) who denied the allegation stating there are no unqualified staff providing medical care. All the Med Techs and the care staff are qualified.

On October 28, 2021, the Department interviewed 5 staff members, including the administrator (S1–S5), about the allegation. 2 of the 5 said some staff may be asked to perform tasks outside their usual scope when needed, but those staff are typically cross-trained in related duties such as medication technician and caregiver tasks. The other 3 staff said they are not asked to perform tasks outside their scope.

On October 28, 2021, the Department interviewed 3 residents (R1–R3). All three residents said they are well cared for and that only medication technicians have administered their medications.

On November 20, 2025, the Department reviewed 4 staff files and found that they contained required certifications and training. Additionally, the Department reviewed and evaluated the staff training certificates (dated: 4/1/21).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211025095214

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: STONEWALL GARDENS ASSISTED LIVING	FACILITY NUMBER: 336426505
	VISIT DATE: 11/20/2025

NARRATIVE

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Allegation: Staff tested positive for COVID

The detail of the complaint alleges that a staff member tested positive for COVID and was asked not to disclose information to other staff.

On November 20, 2025, at 1:15pm, the Department interviewed Nisha Henson, Residential Care Coordinator (A1). A1 denied the allegation and stated the facility has a COVID mitigation plan on file that staff follows.

The complaint alleges a staff member tested positive for COVID and was told not to disclose it to other staff members. COVID test results are confidential, and a positive result is not a violation of Title 22. Interviews and review of documents show the administrator addressed the positive test with staff and arranged testing while maintaining staff confidentiality.

Based on the information gathered there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

There were no deficiencies cited during today's visit.

Exit interview conducted and copy of report provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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