Desert Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Toni Nwala conducted an unannounced visit for a required annual inspection. The LPA was greeted by Administrator Elizabeth Hengstler notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single- story building with 4 residents' bedrooms, 1 staff bedroom, 4 bathrooms, a dinning room, a living room, a kitchen, a laundry room, an outdoor area, and a garage. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen and inaccessible to residents. The smoke detector and carbon monoxide detector were operable. LPA observed fire extnguishers to be in compliance with the department's requirements and with an purchase date of 06-08-2026. The water temperature was tested within regulations measuring 106.2 F Continued 809-C...... Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 12-25-2026 and a Record Review and Resident/Staff Files: LPA reviewed files for 2 staff members, confirming criminal clearance, updated training, and health screening. 3 clients' files were reviewed and contained all required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a closet and located in the hallway. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 07-08-2026, which met the department's requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Aug 19, 2026

Type of visit: Case Management - Other

On March 3, 2026, Community Care Licensing Division (CCLD) held an informal meeting via Microsoft Teams. In attendance were Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Abdoulaye Zerbo, Licensee Elizabeth Hengstler, and Peter Nolan, Attorney representing Desert Cottages. The purpose of this meeting was to serve as the first level of enforcement to address citations issued over the past four(4) years. The following topics were discussed: • Personal Rights violations • Presence of uncleared staff • Reporting requirements • Appeals process During the meeting, the Regional Office offered to refer the licensee to the Technical Support Program (TSP). The licensee requested additional information regarding the TSP prior to making a final decision. The licensee also agreed to submit proof of training on dementia care and reporting requirements to the LPA within 30 days of this meeting.the state’s words, verbatim · CDSS document, Mar 3, 2026

Allegation investigated: Staff is isolating a resident in care.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Staff S1 and explained the reason for the visit. Shortly thereafter Administrator Elizabeth Hengstler arrived. The purpose of the visit is to investigate the above allegation and deliver findings. The initial visit was conducted on 10/16/2024 and included the following: Licensing Program Analysts (LPA) Seo Jeon and Ferrer Sabarias conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. The LPAs met with Destiny Villalta, administrator, and informed them of the purpose of the LPAs' visit. The LPAs conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. At today's visit 2/20/2026 the following was done: Interviews were conducted with the Administrator, Staff S1 and Staff S2. Staff S3 was interviewed during a collateral visit at Desert Cottages II. Resident R1 was also interviewed during a collateral visit at Desert Unsubstantiated Cottages II. Resident's R2- R7 were interviewed at this facility. Power of Attorney (POA) for Resident R1 was interviewed telephonically. A tour of the facility was conducted with LPA observing 4 residents at the dining room table and 2 Residents in the television room. File for Resident R1 was reviewed and the following forms were to be submitted: Admission Agreement, Physician's Reports dated 08/26/2025 and 09/13/2024, Identification and Emergency Information page, Assisted Living Waiver (ALW). Documents reviewed and to be submitted from Comfort Care Hospice included the following: Initial Plan of Care dated 09/16/2024 and Complex/Psycho Social Assessment dated 10/17/2024. In regards to the allegation Staff is isolating a resident in care, based on interviews conducted and information gathered Resident R1 stated that staff at Desert Cottage were wonderful and they went above and beyond. Wasn't able to walk or sit up and staff went out of their way to provide assistance. Stated this has been going on for 20 years. Also stated that there was always interaction with other residents and that staff always would interact and there was never an issue with isolation. Power of Attorney (POA) for Resident R1 stated that staff treated Resident R1 fine. Said that due to being bed bound residents all came to R1's room and would talk for hours. Stated that Resident R1 was never isolated and the facility never did anything out of malice. Resident's R2- R7 all were out of their rooms and 6 out of 6 said that no one tells them to stay in their room and they talk with each other every day in the dining room or television room. Staff S1 and S2 have been here for 5 and 7 years respectively and stated that Resident R1 always interacted with their roommate and other residents would go back and forth to talk with Resident R1. Said that there was never isolation for Resident R1 or any of the other residents. Physician's Reports dated 08/26/2025 and 09/13/2024 under Capacity for Self Care it is checked off that Resident R1 is not able to bathe self, dress self or care for own toileting needs. Listed under Overall Physical Health it is checked off that Resident R1 needs assistance with transferring. Also it is listed in the Assisted Living Waiver (ALW) it states that Resident R1 needs total assistance with ADL's. Comfort Care initial Plan of Care under Information Patient Status it is circled for Resident R1 being bed bound .Document titled Complex/Psycho Social Assessment states under Medical Decision Making that Resident R1 is bed bound. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 18-AS-20241007191717

Allegation investigated: Staff caused injuries to a resident Staff mishandled a resident

Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. It was alleged that staff caused injuries to a resident. During the investigation, the Licensing Program Analyst (LPA) conducted interviews with staff and reviewed relevant records. Interviews revealed a witness to the incident. Staff #2 (S2) reported observing Staff #1 (S1) hitting Resident #1 (R1) on the face. Interviews revealed S1 reported to work on their day off due to staff call off. While assisting residents, S2 heard R1 scream out and went to check. S2 observed S1 lift and throw R1 onto the bed and then picked R1 back up again and throw R1 into the wheelchair. S2 then observed S1 punch R1 in the face. It was at this point S2 intervened, confronted S1 and contacted the police. Law enforcement arrived and observed bruises on R1’s face. Substantiated Based on the bruising and statements made, S1 was arrested. A review of the police report dated 08-25-25 revealed R1 had an abrasion on right arm, which was about one inch in diameter and had blood on it. The report also states that R1 had a bruise on the left side of face on the cheek that was about one inch in diameter. It was reported that R1 had minor redness to the right side of the face near cheek and to the bridge of nose. S1 was interviewed and reported while assisting R1, R1 became resistant and dug their nails into S1. S1 then placed R1 on the bed to allow R1 time to calm down. S1 reported they attempted a second time to assist R1 and was again scratched. When S1 placed R1 back down on the bed, for a second time, their left accidentally made contact with R1’s face. S1 reported this was not intentional and occurred while repositioning the resident. It was alleged that staff mishandled a resident. Concerns were raised that S1 picked up R1 and threw them onto the bed. During the investigation, LPA conducted interviews with three staff members. All interviewed staff stated that while R1 can sometimes be challenging and exhibit aggressive behaviors such as scratching or kicking, they do not believe S1 mishandled R1. Staff described S1 as generally calm and professional when providing care. An interview with S1 revealed that they denied ever mishandling R1 and stated that they always treat residents with dignity and respect. S1 explained that on the day of the incident, they attempted to assist R1 in getting out of bed, but R1 resisted and scratched them. S1 reported that they placed R1 back on the bed to allow time to calm down before attempting again. Although staff interviews generally supported S1’s professionalism, the investigation determined that S1’s own admission of physically placing R1 back on the bed after resistance, combined with the allegation details, supports that inappropriate handling occurred. The action of picking up and placing R1 back on the bed, even if intended to calm the resident, constitutes mishandling under Title 22 because it involved physical force without proper de-escalation techniques. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report and the 9099-D was provided to Licensee Elizabeth Hengstler. An immediate civil penalty was assessed in the amount of $500the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 18-AS-20250825133749

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: Feb 19, 2026

Personnel – Operations (a) In each facility: (2)Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. R1 sustained injuries while in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee agreed to dissociate S1 from facility and send proof of dissociation by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided to Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Feb 18, 2026

Allegation investigated: Staff refused to tell authorized representative who the resident(s) responsible parties were impeding an investigation

Licensing Program Analyst (LPAs) Abdoulaye Zerbo and Aziz Faizi conducted a subsequent complaint visit to deliver the finding for the above allegation. During today’s visit, LPAs met with caregiver Claudia Martinez and explained the reason for the visit. It was alleged Staff refused to give an authorized party, the resident’s responsible party information. Thus impeding an investigation. It was determined the resident in question was Resident #1 (R1). This investigation revealed R1 never resided at this facility. The investigation revealed the correct facility R1 resided at 83-421 MATADOR COURT Indio CA. The investigation will be completed for the correct facility. Based on record reviews and interviews the allegation is unfounded. A finding of unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis. LPA conducted an exit interview and a copy of this report was provided to Caregiver Claudia Martinez Unfoundedthe state’s words, verbatim · CDSS document, Jan 14, 2026 · control 18-AS-20250912082056

Type of visit: Case Management - Other

Licensing Program Analyst (LPAs) Abdoulaye Zerbo and Aziz Faizi conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPAs met with Caregiver Claudia Martinez and explained the purpose of the visit. During the visit, LPAs toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided to Caregiver Claudia Martinezthe state’s words, verbatim · CDSS document, Jan 14, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to conduct a health and safety check and to deliver amended complaint investigation report dated 12-03-2025. Upon arrival, LPA met with Administrator Elizabeth Hengstler and explained the purpose of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. LPA did not observe any health and safety concerns. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

Allegation investigated: Staff are restraining residents Staff are providing THC drinks/Protein powder to residents without a Physicians order Residents are charged for services not rendered Residents moved to other facilities without consent Residents are left unattended Staff put up bed rails without physicians orders

This is an amended complaint investigation report of the original report that was delivered on 05-21-2025. This amended report is created due to being longer than the original report. Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to deliver amended complaint investigation report that was delivered on 05-21-2025 and met with Elizabeth Hengstler, Licensee. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files and records, and obtained supporting documentation to aid in determining the findings of the noted allegations. On December 3, 2024, Community Care Licensing (CCLD) received a complaint report with the following allegations. Continued on LIC9099-C..... Unsubstantiated It was alleged staff are restraining residents. According to the information received, staff are placing weighted vests on residents to keep them immobile. LPA toured and thoroughly searched interior and exterior of the facility but was unable to locate any weighted vest or anything like it. LPA did not observe anything used to physically restrain residents. LPA conducted interviews with five (5) residents, but LPA determined that two (2) out of five (5) residents were unable to be interviewed due to their cognitive condition per attempted interviews. Interviews with the remaining three (3) residents revealed that they have never seen weighted vests or experienced any form of restraint by staff. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied seeing residents wearing weighted vests or any form of restraint. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied ever using any form of restraint or weighted vests on residents. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are restraining residents. This allegation is unsubstantiated. It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. According to the information received, staff are serving THC (Tetrahydrocannabinol) drinks to keep residents sedated and are giving protein drinks without doctor’s order. LPA conducted a tour of interior and exterior of the facility but did not observe any THC drinks or protein drinks. LPA observed nutritional supplements in both liquid and powder forms in the facility kitchen pantry. LPA’s record review revealed that three (3) out of five (5) residents had doctors’ orders for nutritional supplements. LPA conducted interviews with five (5) residents, but none of them knew if they consume nutritional supplements. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, none of whom knew if the residents consumed THC drinks or nutritional supplements. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied serving THC and protein drinks to residents without doctors’ orders. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are providing THC drinks/protein powder to residents without a physician’s order. This allegation is unsubstantiated. It was alleged residents are charged for services not rendered. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied being charged for services or goods not provided. Continued on LIC9099-C.... LPA conducted an interview with the Administrator who stated that the only extra charges would be for services such as haircut(s), podiatry services, or incontinence care supplies LPA’s review of the admission agreement revealed each resident receives basic care services and their charges are aligned with the basic level services. LPA conducted interviews with three (3) staff members, all of whom denied having any knowledge of fees charged to the residents. Based on interviews conducted and file review, there is insufficient evidence to support the allegation that residents are charged for services not rendered. This allegation is unsubstantiated. It was alleged residents moved to other facilities without consent. According to the information received, the Administrator moves the residents around between the two facilities owned by the same Licensee. LPA conducted interviews with five (5) residents, but LPA determined that two (2) out of five (5) residents were unable to be interviewed due to their cognitive condition per attempted interviews. Interviews with the remaining three (3) residents revealed that they have never been moved to another facility for any kind of activities. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied any knowledge of residents being moved to another facility for daytime activities. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom denied moving the residents to another facility for activities. Based on interviews conducted, there is insufficient evidence to support the allegation that residents moved to other facilities without consent is unsubstantiated. It was alleged residents are left unattended. According to the information received, the Administrator frequently leaves the residents alone at night. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA’s review of staff schedule and S1’s live-in employment agreement corroborated the staff members’ statements. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended. LPA conducted interviews with three (3) residents, all of whom stated there are staff members present throughout the day and night. LPA conducted three (3) residents’ responsible persons, all of whom stated there were staff members present whenever they visited. LPA conducted night-time visit and observed staff members were present at the facility. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that residents are left unattended. This allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged staff put up bed rails without physician’s orders. LPA observed one (1) of five (5) residents with full bed rails. LPA observed three (3) of five (5) residents have half bed rails. LPA’s file review revealed Resident #1 had doctor’s order for full bed rails, and Residents #2, #3, and #4 also had doctor’s orders for half bed rails. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that staff put up bed rails without physician’s orders. This allegation is unsubstantiated. Based on records review, resident interviews, and staff interviews, above allegations are 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. It was alleged staff are restricting visiting hours. According to the information received, there is a visiting hour posted at the facility door, and visitors must call before visiting. During the tour of the facility, LPA observed a sign at the facility door showing visiting hours of 10:00 AM to 6:00 PM. The sign also showed requirement for visitors to obtain approval for visitation during mealtimes. LPA conducted interviews with three (3) out of five (5) residents’ responsible persons, all of whom denied experiencing any restriction with visitation. However, the three (3) responsible persons stated they usually call the Licensee if they are visiting outside the posted visiting hours. Other two (2) residents’ responsible persons were unavailable for an interview. LPA conducted interviews with four (4) staff members, all of whom stated no visitors have been denied entry to the facility outside of the visiting hours if the visitors get approval from the Licensee. Based on the interviews conducted and observation, there is sufficient evidence to support the allegation that staff are restricting visiting hours. 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, along with a copy of LIC9099C, LIC9099D, and Appeal Rights were provided. ***LPA Seo Jeon conducted subsequent visit to deliver amended LIC9099-D with new plan of correction.the state’s words, verbatim · CDSS document, Dec 3, 2025 · control 18-AS-20241203155436

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Dec 31, 2025

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have... (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to...during reasonable hours and without prior notice Based on LPA's observation, the Licensee posted visiting hours at the entrance of the facility which poses potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2025

Plan of correction: Licensee will remove the visiting hour sign and send proof of having personal rights training by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Nov 26, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Licensee Elizabeth Hengstlerthe state’s words, verbatim · CDSS document, Oct 24, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Caregiver Rhonda Wilts and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided to Caregiver Rhonda Wiltsthe state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and conducted interviews with residents. No immediate health or safety concerns were observed at the time of the visit. However, LPA noted that the toilet tank in the master bedroom was in disrepair. The Licensee stated that maintenance will address the issue by the end of the weekend. An exit interview was conducted, and a copy of this report was provided to Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and no immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Claudia Martinez and explained the purpose of the visit. Licensee Elizabeth Hengstler joined the visit at a later time. During today's visit, LPA toured the facility and no immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Sep 26, 2025

Allegation investigated: Staff denied resident visitors Due to staff neglect, resident had multiple unexplained bruises Staff overmedicated resident Staff did not notify authorized representative of incidents Staff increased medication without authorization

On 09/19/2025, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced visit to the facility to deliver an amended version of the original report regarding the allegations listed above. LPA met with Licensee, Elizabeth Hengstler who was informed of the purpose of the visit. The alleged victim has been identified as Resident 1 (R1). Licensee Hengstler reported R1 never resided in this facility. LPA contacted R1’s responsible person who confirmed R1 never resided in this facility. LPA reviewed R1’s admission agreement signed and dated 08/30/2023, noting the agreement is with a different facility located at a different address. Therefore, the allegations noted above are unfounded. Unfounded means the allegations are false, could not have happened and/or are without a reasonable basis. The Department has opened a complaint at the facility R1 resided at to investigate the allegations. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Licensee Hengstler. Unfoundedthe state’s words, verbatim · CDSS document, Sep 19, 2025 · control 18-AS-20230922152416

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and no immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstlerthe state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Rhonda Wilts and explained the purpose of the visit. During today's visit, LPA toured the facility, conducted interviews and records review. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Caregiver Rhonda Wilts.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler, informed them of the purpose of the visit and was granted access. During today's visit, LPA toured the facility and no immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Case Management - Other

On 8/30/2025, Licensing Program Analysts (LPA) Armando Perez arrived unannounced to the facility to conduct a case management visit. LPA was greeted and granted entry by Caregiver Claudia Martinez, who was informed of the purpose of the visit. Licensee/Administrator Elizabeth Hengstler arrived to the facility at a later time and was also informed of the purpose of the visit. During today's visit, LPA conducted a health and safety visit. LPA toured the facility’s interior and exterior with Licensee/Administrator Elizabeth Hengstler. LPA conducted interviews with clients and obtained pertinent documents. No health and safety concerns were observed during today's visit. No citations were issued during today’s visit. An exit interview was conducted, and this report was reviewed and a copy was provided to Licensee/Administrator Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Aug 30, 2025

Type of visit: Case Management - Other

On 8/27/2025, Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez arrived unannounced to the facility to conduct a case management visit to deliver an Immediate Exclusion order for Staff, Destiny Villalta. LPA were greeted and granted entry by Caregiver Rhonda Wilts who was informed of the purpose of the visit. Licensee/Administrator Elizabeth Hengstler arrived to the facility at a later time and was also informed of the purpose of the visit. During today's visit, LPAs toured the facility’s interior and exterior with Licensee/Administrator Elizabeth Hengstler. LPAs provided Licensee Elizabeth Hengstler the Immediate Exclusion order dated 8/27/2025 regarding Villalta. No citations were issued during today’s visit. An exit interview was conducted, and this report was reviewed and a copy was provided to Licensee/Administrator Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: Staff are chemically restraining residents in care. Staff are physically restraining residents in care. Food services are inadequate.

Licensing Program Analyst (LPA) Yolanda Delgado conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Yolanda Delgado met with Elizabeth Hengstler and explained the reason for the visit. On 4/11/2024, the Riverside Adult and Senior Regional Office (RO) received a complaint regarding allegations of staff are chemically restraining residents in care, it is alleged that staff are giving THC drinks to keep residents sedated, staff are physical restraining residents in care, it is alleged that staff are placing weighted vests on residents to keep them immobile, at bedtime to keep them in bed and side rails are attached to aid in restraining, food services are inadequate, it is alleged that staff give residents protein drinks without doctors’ orders. (Continued on Page 2) Unsubstantiated (Continued from Page 1) On the allegation: Staff are chemically restraining residents in care. It was alleged staff are giving THC drinks to keep residents sedated. LPA did not observe any drinks labeled with THC in the pantry, other cabinets, drawers inside the kitchen, did not observed any prescribed medications for clients for THC. Interviews were conducted with Staff and witness did not corroborate that residents are given THC. Medication lists for Resident #1 (R1) and Resident #2 (R2) were reviewed by LPA revealed residents have a doctor’s order for Nutrilite sleep Health which is a supplement were prescribed for R1 and R2, it is not THC. On the allegation: Staff are physically restraining residents in care. It was alleged staff are placing weighted vests on residents to keep them immobile, at bedtime to keep them in bed and side rails are attached to aide in restraining. LPA conducted a tour of the resident bedrooms and common areas and observe a resident wearing a light blue color terry cloth bib that is attached by a snap button laying in bed watching TV eating food. The bib did not weigh 20 pounds, is made from fabric and is used by residents that may need assistance in keep their clothes clean, a half side rail was observed in one resident room that was attached to the bed and it was half a rail not a full rail, LPA did observe a doctor order for rails to be used for resident. LPA did not observe any weighted vests and rails stored inside resident’s closets, garage or laundry areas. Interviews were conducted with Staff and witness did not corroborate that staff are physically restraining residents. On the allegation: Food Service are inadequate; it is alleged that staff give residents protein drinks without doctors’ orders. LPA reviewed food supply in the kitchen areas and there is enough food supply and there are different options that residents are prepared to eat. LPA observed snacks given to residents at the dining table during the afternoon on a visit at the facility. LPA observed Nurtrilite organics all-in-one shakes and a bag plant protein powder inside the pantry. LPA observed doctor’s orders for the protein drinks for (R1) and (R2). Interviews were conducted with Staff and witness did not corroborate that food service is inadequate, and residents are being given protein drinks without doctor’s orders. Based on records review, staff interviews and witness’s interviews, above allegations are 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 with Elizabeth Hengstler and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 18-AS-20240411143908

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care regarding a complaint report received on 12-03-2024. LPA met with Destiny Villalta, Administrator, who allowed LPA entry. LPA was informed that five (5) residents currently reside at this facility. There were three (3) staff on duty during the time of the visit. LPA toured the facility. LPA conducted interviews with staff. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. LPA did not observe any immediate health and safety concerns for residents in care. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Administrator Destiny Villata, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single- story building with 4 residents' bedrooms, 1 staff bedroom, 4 bathrooms, a dinning room, a living room, a kitchen, a laundry room, an outdoor area, and a garage. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen and inaccessible to residents. The smoke detector and carbon monoxide detector were operable. LPA observed fire extinguishers to be in compliance with the department's requirements and with an expiration date of 04-25-2026. The water temperature was tested within regulations measuring 111.2 F Continued 809-C...... Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 12-04-2026 and a CPR certification with the expiration date of 01-15-2027. Record Review and Resident/Staff Files: LPA reviewed files for 2 staff members, confirming criminal clearance, updated training, and health screening. 2 clients' files were reviewed and contained all required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a closet and located in the hallway. LPA reviewed medications for 2 residents confirming that all medication were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 08-04-2025, which met the department's requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Destiny Villatathe state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Seo Jeon and Janette Romero made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report #18-AS-20241203155436. LPA met with Destiny Villalta, Administrator, who allowed LPA entry. LPA toured the inside and outside of the facility. LPAs conducted interviews with staff and residents. LPAs obtained pertinent documents from the Administrator. LPAs did not observe any health and safety concerns at this time of visit There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report were provided.the state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Staff are restraining residents Staff are proving THC drinks/Protein powder to residents without a Physicians order Staff are restricting visiting hours Residents are charged for services not rendered Residents moved to other facilities without consent Residents are left unattended Staff put up bed rails without physicians orders

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit for additional investigation and met with Destiny Villalta, Administrator. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files, and records, and obtained supporting documentation to aid in determining the findings of the noted allegations. On December 3, 2024, Community Care Licensing (CCLD) received a complaint report with the following allegations. It was alleged staff are restraining residents. LPA toured interior and exterior of the facility. LPA did not observe anything used to physically restrain residents. LPA interviewed (3) three residents, but no one confirmed they had experienced any form of restraint. LPA interviewed two (2) staff members, but both denied using any form of restraints on residents. Continued on LIC9099-C Unsubstantiated It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. LPA toured interior and exterior of the facility. LPA did not observe any THC drinks in the facility. LPA observed supplementary drinks with protein in the pantry. 3 out 5 residents consume the protein drinks. LPA observed doctor’s orders for the protein drinks in those three (3) residents files. It was alleged staff are restricting visiting hours. LPA observed the facility visiting policy outlining visiting hours next to the front door. Staff members confirmed visitors who come after hours will be allowed entry after calling the licensee. Staff members stated they have never turned away any visitors. It was alleged residents are charged for services not rendered. LPA’s interview with the administrator revealed the only extra charge to the resident’s account will be the incontinence supplies. LPA’s review of the admission agreement revealed each resident receives basic care services and their charges are aligned with the basic level services. It was alleged residents moved to other facilities without consent. LPA’s interview with the administrator revealed residents sometimes visit another facility owned by the same licensee when there are community activities. LPA observed three (3) residents receiving haircuts, and one of the residents returned to their home facility after their haircut. It was alleged residents are left unattended. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA reviewed the staff schedule and S1’s live-in employment agreement. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended. It was alleged staff put up bed rails without physician’s orders. LPA observed 1 of 5 residents with full bed rails. LPA observed 3 of 5 residents have half bed rails. LPA’s file review revealed resident #1 has doctor’s order for full bed rails, and residents #2, #3, and #4 also have doctor’s orders for half bed rails. Based on records review, resident interviews, and staff interviews, above allegations are 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.the state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20241203155436

Allegation investigated: Resident sustained an unwitnessed fall resulting in a fracture.

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to deliver investigation findings for the above listed allegation. LPA met with Licensee, Elizabeth Hengstler, who was informed of the purpose of the visit. The investigation consisted of Department conducted record reviews and interviews. The records reviewed include monthly care plans for Resident 1 (R1), the admission agreement for R1, the needs and service plan for R1, medical records for R1 and the facility Program Plan. Interviews were conducted with 3 residents, one of which was the victim, 2 family members of R1, the Ombudsman, 3 facility staff members and the facility Administrator. Substantiated Hospital medical records document on 03/09/2022 R1 was transported to a local hospital and was diagnosed with an angulated overriding right intertrochanteric fracture. Staff provided inconsistent accounts of the incident surrounding R1’s fall. The licensee reported live-in night shift staff, Staff 1 (S1), sleeps throughout the night. S1 will check on residents at 2300 hours and then sleeps until morning when residents start to awaken between 0630 and 0700 hours. S1 corroborated this and indicated they do not check on residents unless summoned by residents. Staff interviews revealed AM staff arrive at 0700 hours. Staff 2 (S2) reported finding R1 at 0700 hours on 03/09/2022 on the floor of R1’s bedroom. S2 was unaware of how long R1 was on the floor before being found. The licensee corroborated being called to R1’s bedroom by S2 at 0700 hours and finding R1 on the floor. S1 reported they slept at the facility but were not “on duty” the day prior and the day of the incident. There were no other staff present during the night shift. S1 reported even when they are off duty they would listen for residents and assist them if needed. S1 reported they did not observe or hear anything unusual the night of the incident. Staff consistently reported R1 required assistance of wheelchair and walker when ambulating. However, staff keeps these devices out of eyesight, so R1 is not tempted to access the devices independently. During a visit by Department staff on 06/13/2022, the Department staff observed R1’s wheelchair to be placed out of sight of R1 approximately 10 feet away. The Desert Cottage Program Plan documents, “at least two caregivers will be available to the residents at all times.” Facility Admission Agreement for R1, dated 05/17/2021; documents R1 is receiving Level 2 services which are for residents that rely on the facility for extensive assistance with personal activities of daily living and includes residents who are a fall risk or have declining mobility. Basic services in the admission agreement include continuous care and supervision. Based on the interviews conducted and the records reviewed, the facility was not sufficiently staffed to meet the basic service requirements of the Admission Agreement or the Program Plan and therefore the allegation of Neglect/Lack of Care and Supervision is SUBSTANTIATITED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR). A lack of care and supervision resulted in R1 suffering a fall with serious bodily injury therefore, an immediate $500 civil penalty is being assessed on this day in accordance with Health and Safety Code Section 1569.49(e). The determination of additional civil penalties are under review, and a determination is pending by the Department. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list were provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 18-AS-20220330113756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3) · Plan of correction due date: Jan 10, 2025

(c) (3) "Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: This requirement was not met as evidenced by: Based on the Department’s records review and interviews conducted the Licensee did not ensure sufficient staffing levels were provided as specified by the Program Plan and Admission Agreement. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: The Licensee agrees to submit an attestation that caregivers will be available to the residents as specified by the Program Plan.

Allegation investigated: Staff did not provide comfortable accommodations to resident in care

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate the complaint investigation regarding the allegation above. LPA conducted a tour of the facility, staff and resident interviews, and requested pertinent documents related to the investigation. Regarding the allegation "Staff did not provide comfortable accommodations to resident in care", it was reported the facility did not have comfortable accommodations and the room temperature was very hot for Resident One (R1). LPA conducted interviews with three (3) residents who denied the facility being hot and uncomfortable. During the visit, LPA observed the thermostat set at 83 degrees Fahrenheit. LPA observed all six (6) residents wearing cardigans or having a blanket covering them during the visit. Interview with Resident Two (R2) revealed the temperature in the facility is comfortable. Interview with R1 reported their room was always hot and staff had provided a fan to help accommodate R1. Unsubstantiated Interview with Staff One (S1) reported when R1 informed staff they were hot, a fan was provided to R1 to provide a comfortable environment. Interview with Staff Two (S2) reported if a resident were to inform staff they were cold, S2 would give them a jacket or blanket. S2 reported if residents were to inform staff they were hot, they would provide a fan for cooler air. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 18-AS-20240930104506

Type of visit: Required - 1 Year

On 8/21/24 Licensing Program Analyst's (LPAs) Valerie Flores, Ferrer Sabarias, and Andrei Castillo conducted an unannounced one (1) year required visit. LPA's were granted entry by caregiver, Claudia Martinez, who was informed of the purpose of visit. At the time of the visit there were two (2) staff, Administrator and five (5) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA's observed the following during today's visit: LPA's conducted a tour of the facility with staff member, Claudia Martinez. The physical plant contained four (4) resident bedrooms, one (1) staff bedroom, and four (4) bathrooms. The facility has a dining room, kitchen, living room, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Water temperature measured at 111.3-degree Fahrenheit meeting within the required limits. LPA's observed a refrigerator with non-perishable foods in the garage along with emergency food and water. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked cabinet. Resident bedrooms had the required bedding, furniture, and lighting. Disinfectants and cleaning solutions were secured in a locked cabinet in the kitchen. The smoke and carbon monoxide detectors were tested and were observed to be operable. LPA's observed charged fire extinguishers mounted in the kitchen. Staff files reviewed have a criminal record clearance and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, appraisals, and needs and service plan. Facility sketch, personal rights, and emergency disaster plan is posted on a wall in the dining room. According to Administrator, Elizabeth, there are no firearms or ammunition on the premises. During today's visit, LPA's did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Aug 21, 2024