Desert Hills Memory Care Center

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility management retaliated against staff member Facility is not following their plan of operation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 1/30/24 LPA Ross conducted initial investigation visit. On 12/1/25 LPA Flores requested pertaining documents. On 12/3/25 LPA Flores conducted interviews with 6 residents and 6 staff. On 12/4/25 LPA Flores delivered findings. The investigation revealed the following: Regarding allegation: Facility management retaliated against staff #1(S1). It is alleged licensee retaliated against staff for bringing up concerns. . Interviews with residents revealed residents did not have concerns about the staff. Interviews with 6 staff revealed 6 out of 6 staff stated management has not retaliated against the staff. 1 out of the 6 stated there was a staff in management before that was difficult to communicate with and 1 out of the 6 staff mentioned they raththe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 18-AS-20240126082906

Allegation investigated: Staff are not addressing an outbreak of scabies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 7/10/24 LPAs Martinez and V. Flores conducted initial investigation visit. On 12/1/25 LPA Flores contacted administrator and requested pertaining documents and attempted to contact Riverside Department of Public Health (RDPH). On 12/1/25 and 12/2/25 LPA Flores attempted to contact RDPH. LPA On 12/3/25 LPA Flores interviewed 6 residents and 6 staff, and reviewed 6 resident files. On 12/4/25 LPA delivered findings. The investigation revealed the following: Regarding allegation: Staff are not addressing an outbreak of scabies. It is alleged residents at the facility have scabies. (CONTINUED ON LIC 9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 18-AS-20240702131513

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not keep facility free of pests

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 8/20/24 LPAs Jeon, Castillo and Sabarias conducted an initial complaint investigation, conducted a tour of the facility, interviewed 3 staff and 2 residents, and requested pertaining documents. On 10/25/24 LPA Jeon conducted a subsequent visit and interviewed 7 residents. On 12/1/25 LPA Flores requested pertaining documents for resident #1(R1). On 12/3/25 LPA Flores conducted a tour of the facility, interviewed 6 staff, and delivered findings. The investigation revealed the following: Regarding allegation: Staff did not keep facility free of pest. It is alleged facility has bedbug infestation. (CONTINUED ON LIC 9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 3, 2025 · control 18-AS-20240812155053

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility Staff do not ensure sufficient supplies are available Staff are drinking on the facility premises

*This is a corrected version and supersedes report dated: 11/19/25 to correct finding noted on report from Needs Further to Unsubstantiated.* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 8/22/23 LPA Martinez conducted an initial complaint investigation visit and requested the pertinent documents. On 12/18/23 LPA Martinez conducted a subsequent complaint visit. On 1/23/24 LPA Martinez conducted a subsequent visit and interviewed residents. On 11/7/25 LPA Flores contacted administrator and requested physician’s reports, face sheets, incident reports for 9 residents. On 11/8/25 LPA Flores interviewed 3 staff over the phone. On 11/10/25 LPA Flores contacted Riverside Department of Public Health. (CONTINUED ON LIC 9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 21, 2025 · control 18-AS-20230814115217

Allegation investigated: Resident sustained injuries while in care Staff handled resident in a rough manner Staff are overdosing resident Staff left resident in soiled clothing for extended period of time Staff did not safeguard residents personal belongings

On May 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Licensee, Shannon Moore. LPA explained the reason for the visit was to provide findings for the complaint investigation. On March 21, 2022, Community Care Licensing received a complaint alleging, Resident sustained injuries while in care,Staff handled resident in a rough manner, Staff are overdosing resident, Staff left resident in soiled clothing for extended period of time, and staff did not safeguarded residents personal belongings. During the investigation LPA conducted interviews, record reviews, and made observations. Regarding the allegation Resident sustained injuries while in care, it was reported R1 sustained a serious knee injury. It was also reported that R1’s knee was swollen and R1 was unable to move it. Information obtained from interview with Executive Director, Chantelle Hudson advised R1 had no falls and injuries reported during placement. Executive Directorthe state’s words, verbatim · CDSS document, Jun 6, 2025 · control 18-AS-20220321154449

Allegation investigated: Staff do not ensure that resident's dental needs are being met. Resident's room is in disrepair. Staff are preventing resident from leaving the facility.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Executive Director, Shannon Moore, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented conducted a walk through, and conducted records review. It was alleged that “Staff are preventing resident from leaving the facility.” It was alleged that Resident #1 (R1) had legally revoked their Power of Attorney (POA) and became self- responsible on 01/16/2024. It was alleged that R1 was not allowed to leave the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 19, 2025 · control 18-AS-20240122095107

Allegation investigated: Staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care.

On 04/24/25 Licensing Program Analysts (LPA)s Abdoualye Zerbo and Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation noted above. LPA met with Lavina Dubose, Memory Care Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and record review. On 04/16/25 Community Care Licensing received a complaint alleging staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care. Per interview with Executive Director Shannon Moore, there has not been any incidences as alleged to have occurred with individuals outside of the facility being granted access to the facility and attacking any residents in care. Per a file review the facility is a secured perimeter and requires a door code to be granted entry to each buidling on the premises. Interviewthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 18-AS-20250416103400

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility retaining residents who need a higher level of care.

Licensing Program Analysts (LPAs), Stephanie Martinez and Ferrer Sabarias, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPAs met with Administrator, Shannon Moore Wilkerson, and informed her of the purpose of the visit. A report was received by the Department alleging the licensee admits residents into the facility who have a mental disorder requiring a higher level of care than can be met by the facility. The investigation included staff interviews, review of records and collection of relevant documentation. An interview with a witness revealed there are at least two residents in care who do have a mental disorder requiring a higher level of care. LPA Martinez reviewed the medical assessments (Physicians Report for Residential Care Facility for The Elderly) for both residents identified, Resident One (R1) and Resident Two (R2). Neither report noted either R1 or R2 were diagnosed with a mental disorder as allthe state’s words, verbatim · CDSS document, Aug 22, 2024 · control 18-AS-20240131082100

Allegation investigated: Unqualified staff giving residents injections

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Shannon Wilkerson, Administrator, and informed her of the purpose for the visit. A report was received alleging residents in care are receiving injections from unqualified staff. According to Administrator Wilkerson, there has only been two residents in care, in the last four (4) months, who have required injections. She reported it is only the staff who have a LVN (Licensed Vocational Nurse) license, or herself, who will administer injections to residents in care. Staff interviews and records refuted the Administrator’s statement. Two out of four staff interviews revealed medication technicians, who are not considered appropriately skilled professionals, have been observed to administer injections to residents in care. In addition, Resident One's (R1's) and Resident Two's (R2's) Medication Administration Records, rethe state’s words, verbatim · CDSS document, Feb 8, 2024 · control 18-AS-20240131082100

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Inappropriate interactions between resident's in care.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Shannon Moore informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff and residents; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined. Allegation #1 – Inappropriate actions between residents in care. The allegation stated that Resident One (#R1) was involved in a physical altercation with Resident Two (#R2). Allegedly, R1 threw a punch, and struck R2. When R1 punched R2, R2 bit R1 on the hand, causing a minor breakage of the skin. Staff interview revealed that both Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 3, 2024 · control 18-AS-20211213172614