Desert Cottage II

Type of visit: Collateral

Licensing Program Analyst (LPA) Glenn Trueman and conducted an announced visit to the facility to conduct an interview with Resident One (R1) regarding an open complaint unrelated to this facility. LPA met with Elizabeth Hengstler, licensee, who was informed of the purpose for the visit. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Feb 20, 2026

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, Feb 18, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (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 Teri Duet and explained the purpose of the visit. Licensee Elizabeth Hengstler joined the visit at a later time. 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 Licensee Elizabeth Hengstler.the 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 Licensee 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 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 two (2) residents, both of whom stated that they have never seen weighted vests or experienced any form of restraint. LPA conducted interviews with two (2) residents’ responsible persons, all of whom denied seeing residents wearing weighted vests or any form of restraint. LPA conducted interviews with two (2) staff members, both 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 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 and observed THC drinks in the facility refrigerator. LPA also observed nutritional supplements in both liquid and powder forms in the facility kitchen pantry. LPA’s record review revealed that both residents had doctors’ orders for THC drinks and nutritional supplements. LPA conducted interviews with two (2) residents, but none of them knew if they consume THC drinks or nutritional supplements. LPA conducted interviews with two (2) residents’ responsible persons, both of whom acknowledged that residents consumed THC drinks and nutritional supplements. LPA conducted interviews with two (2) staff members, both of whom confirmed that both residents had doctors’ orders for THC drinks and nutritional supplements. 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 two (2) residents’ responsible persons, both of whom denied being charged for services or goods not provided. LPA conducted an interview with the Administrator who stated that the only extra charges would be for services like haircut, 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. 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. Continued on LIC9099-C.... 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 two (2) residents, all of whom stated there are staff members present throughout the day and night. LPA conducted two (2) residents’ responsible persons, all of whom stated there were staff members present whenever they visited. LPAs conducted nighttime 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. It was alleged staff put up bed rails without physician’s orders. LPA observed one (1) resident with full bedrails and another resident with half bedrails. LPA’s file review revealed both residents had doctors’ orders for their bedrails. 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 two (2) residents’ responsible persons, both of whom denied experiencing any restriction with visitation. However, the two (2) responsible persons stated they usually call the Licensee if they were visiting outside the posted visiting hours. LPA conducted interviews with two (2) staff members, both 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. 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’s interviews with two (2) residents revealed that the Administrator moves one (1) of the two (2) residents to Desert Cottage (facility #336423671) during daytime for activities. LPA conducted an interview with the Administrator who acknowledged that they moved one (1) of the two (2) residents to other facility for activities. However, the Administrator stated they did not have written agreement from the resident’s responsible person. Based on interviews conducted, there is sufficient evidence to support the allegation that residents moved to other facilities without consent 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-20241203161122

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...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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Dec 31, 2025

Additional Personal Rights of Residents in Privately Operated Facilities...(a) In addition to the rights listed in Section 87468.1, Personal Rights...(6) To make choices concerning their daily lives in the facility. Based on LPA's observation, the Licensee did not have acknowledgement from the residents' responsible persons prior to moving the residents to other facilities for daily adcitivities which poses potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2025

Plan of correction: Licensee obtained written acknowledgement from the residents' responsible persons in the first week of August 2025. Correction has already been made. Licensee will send copies of the signed acknowledgements 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 Caregiver Teri Duet and explained the purpose of the visit. Licensee Elizabeth joined the visit at a later time. 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 Caregiver Teri Duet.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 for a health an safety check. The LPA met with Caregiver Teri Duet and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Caregiver Teri Duet.the 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 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 conducted interviews. 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 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 Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. 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 10, 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 Caregiver Terri Duet, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Licensee Elizabeth Hengstler joined the visit at a later time. Facility Overview: The facility is a single- story building with 3 residents' bedrooms, 1 staff room, 3 bathrooms, a dinning room, a living room, an office area, 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 area and inaccessible to residents in care. The smoke detectors and carbon monoxide detectors were operable. LPA observed fire extinguisher to be in compliance with the department's requirements and with an expiration date of 04-02-2026. The water temperature was tested within regulations measuring 105.9 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 CPR certification with the expiration date of 01-15-27. Record Review and Resident/Staff Files: LPA reviewed files for 2 staff members, confirming criminal clearance, updated training, and health screening. 2 residents' 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 cabinet and located in the Kitchen area. LPA reviewed medications for 1 resident 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 10-03-2025, 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 Licensee Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Oct 3, 2025

Allegation investigated: Staff physically abused resident in care.

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 and records review. On 12-06-2023, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff physically abused resident in care. Information received indicated Resident #1 (R1) was physically abused by Staff #1 (S1). According to a relevant party, R1 was observed with bruises on the right side of their body, head, and face. R1 was also observed with cuts on their forehead. Relevant party informed the Licensee regarding the alleged physical abuse by S1, but the Licensee denied knowledge of any type of physical abuse going on at the time. Continued on LIC9099-C.... Unsubstantiated LPA’s file review indicated R1 was admitted to the facility in April 2023, placed under hospice care in August 2023, and moved out on 12-06-2023 to another facility. R1 passed away in September 2024. R1 was the only resident at the time of the alleged abuse. During the investigation, LPA interviewed R1’s relevant party, who relayed a disturbing account allegedly shared by R1 that S1 had dragged R1 across the floor from the bathroom to the bed, forcefully thrown R1 onto the bed, and slapped R1 multiple times after a fall near the toilet. LPA attempted to interview two (2) staff members from the hospice agency, but it was unsuccessful. R1 had a roommate, but that person passed away in October 2023, so no interview was conducted. LPA conducted interview with two (2) staff members including S1, both of whom denied the alleged physical abuse took place. LPA learned there was a police report generated from an incident that occurred on 11-25-2023 related to R1. LPA obtained and reviewed the police report from Indio Police Department. The information obtained from the police report did not contain supportive evidence to corroborate the allegation. Based on records review and interviews conducted, the allegation that staff physically abused resident in care 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.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 18-AS-20231206152231

Allegation investigated: 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

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 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.... 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.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 18-AS-20241210103507

Allegation investigated: Staff are placing restraint vests on residents in care.

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 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. 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.... 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.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 18-AS-20240408110606

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(3) · Plan of correction due date: Sep 30, 2025

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: 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.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Licensee will ensure staff will adhere to personal rights regulation.

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 conducted interviews. 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 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 Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. 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 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 Caregiver Terri Duet, informed them of the purpose of the visit and was granted access. Licensee Elizabeth Hengstler arrived at a later time. During today's visit, LPA toured the facility, obtained pertinent documentation and conducted interviews. 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

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Terri Duet, informed them of the purpose of the visit and was granted access. During today's visit, LPA toured the facility, obtained pertinent documentation and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Caregiver Terry Duet.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. LPAs were greeted and granted entry by Licensee/Administrator Elizabeth Hengstler who was informed of the purpose of the visit. During today's visit, LPAs toured the facility’s interior and exterior with Licensee/Administrator Elizabeth Hengstler and collected pertinent documentation. LPAs provided Caregiver Destiny Villalta with the Immediate Exclusion order dated 8/27/2025 and LPAs observed Destiny Villalta leave the premises after issuance of the letter. 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

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding complaint control numbers 18-AS-20240408110606 and 18-AS-20241210103507. 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. LPA obtained pertinent documents from the Administrator. LPA 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, Aug 22, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report received on 12-06-2023. 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 resident. LPA obtained pertinent documents from the Administrator. LPA 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, Aug 21, 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-20241203161122. 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

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility for a health and safety check. LPA met with Administrator Destiny Villalta, identified himself and discussed the purpose of the visit. A tour of the facility was conducted. No immediate health and safety concerns were observed during the visit. During today’s visit, LPA interviewed residents and staff and conducted records review. LPA verified facility does not have bedridden residents. An exit interview was conducted, and a copy of this report was provided to Administrator Destiny Villaltathe state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a case management. The LPA met with Facility Administrator Destiny Villalta, and informed her of the purpose for the visit and were granted access. The facility is a single story building and consists of three(3) resident rooms, one(1) staff room and three (3) bathrooms. The LPA obtained copies of relevant documentation such as the LIC 500 Personnel Report and client roster. LPAs observed current personnel to be fingerprint cleared and listed on the facility's personnel report. There is currently one (1) resident in care. LPA's case management included interview with management and resident, obtaining relevant documentation and conducting a tour of the facility for a health and safety check. No health and safety concern were observed during today's visit. Further review is needed at this time. Possible visits and phone interviews will be conducted before a decision is rendered. An exit interview was conducted, and a copy of this report was provided to Administrator Destiny Villalta.the state’s words, verbatim · CDSS document, Dec 11, 2024

Allegation investigated: Neglect/lack of care and supervision resulting in Resident #1 (R1) sustaining unexplained injuries.

On 11/26/2024 Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to deliver complaint investigation findings for the above allegation. After introducing and identifying self, LPA met the Administrator Destiny Villalta to discuss the findings. On February 19, 2020, the Department received a complaint with allegation of personal rights violation resulting in R1 sustaining unexplained injuries. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals. Investigation revealed that on or around February 10, 2020, R1 was observed with injuries including hematoma (as described by observer) on right arm of R1, and bruise on left arm of R1. In addition, R1 was observed with a swollen lip. Substantiated During the investigation, interviews were conducted with S1, S2, S3, and other pertinent individuals. Investigation revealed that prior to injuries observed, R1 was at the facility. Interviews with S1, S2, S3 further support awareness of injuries and that the injuries were sustained at the facility. However, there were conflicting accounts provided by S2 and S3 as to how R1 sustained or could have sustained the injuries. In addition, S1 reported that S1 was not aware of the injuries until another party reported it to S1. Based upon a review of R1 records, services such as continuous care, supervision, and observation for changes in physical, mental, emotional, and social functioning was to be provided. In addition, services such as assistance with declining mobility and behavioral issues are also indicated as being provided to R1. However, the preponderance of evidence supports that facility staff failed to provide the identified care and supervision to R1 on or around February 10, 2020. As a result, R1 sustaining unexplained injuries. The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed, and copies provided to the Administrator Destiny Villalta. However, the manner in which injuries were sustained could not be confirmed to have occurred as a result of physical abuse by staff. There were no witnesses identified who confirmed physical abuse. 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 at this time. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Administrator Destiny Villaltathe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 18-AS-20200219153407

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Nov 26, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based upon review of facility and other records, observations, and interviews with pertinent individuals, licensee failed to ensure that R1 was provided with care, supervision, and services required. As a result, R1 sustained injuries while at facility. This violation posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: The licensee shall conduct in-service training to all staff in regard to the residents’ personal rights. Proof will be submitted to the Department by 12/10/2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by licensee Elizabeth Hengstler, notified her of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with 4 bedrooms and 3 bathrooms. There is no gated pool and there are no firearms on the premises. Infection Control: LPAs 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 requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were tested and were operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 12/2025. LPAs observed the hot water temperature to meet requirements at 109.1°F. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of December 25th, 2024. Continued on LIC809-C..... Record Review and Resident/Staff Files: LPAs reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. One resident's file was reviewed and contained all required documentation. LPA's observed Staff, resident files, first aid kit were locked in a cabinet in the kitchen, and PPE's, emergency food and water were stored in the garage. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked located in the kitchen cabinets.. Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 7-1-2024, which met department 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 Elizabeth Hengstlerthe state’s words, verbatim · CDSS document, Oct 16, 2024

Type of visit: Collateral

Licensing Program Analysts (LPA) Seo Jeon and Ferrer Sabarias conducted an announced visit to the facility to conduct an interview with Resident One (R1) regarding an open complaint unrelated to this facility. LPA met with Elizabeth Hengstler, licensee, who was informed of the purpose for the visit. During today's visit, LPA did not observe any issues or concerns. An exit interview was a conducted and a copy of this report was reviewed and provided to Elizabeth Hengstler.the state’s words, verbatim · CDSS document, Oct 16, 2024

Allegation investigated: Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries Staff overmedicated resident

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Destiny Villalta, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. LPA Banrasavong was unable to conduct interviews with additional witnesses who were employed with the hospice company. On 09/18/2023, Community Care Licensing received a complaint alleging that facility staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries and staff overmedicated resident. In regards to the allegation that staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries, it was reported that the resident had several bruises and skin tears. During the investigation, LPA conducted an interview with an additional witness who stated they had pictures of the bruises and skin tears. It was later stated that the additional witness did not have any pictures to provide. (Continued on 9099-C) Unsubstantiated (Continuation from 9099) Based on the interviews and review of pertinent information, the allegation of facility staff did not properly keep records of medication being dispensed, has been unfounded. This agency has investigated the complaint and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to the Administrator, Destiny Villalta. (Continuation from 9099) Information obtained from the additional witness further stated there were no photographs or pictures taken during the time of the time frame of the alleged incident. Information obtained from staff interviews stated that there was adequate staffing present to care for the residents. Information obtained from interviews with residents stated that they felt that the staff were attentive to their needs and that they received helped in a timely manner. Facility staff stated that they ensured all required advisements were reported to the hospice company, Community Care Licensing (CCL), and responsible party when incident(s) occurred. CCL did receive a serious incident report from the resident regarding a fall with injury. It was advised that there were no concerns regarding the supervision of residents. In regards to the allegation that staff overmedicated the resident, it was reported that R1 was given a higher level of dosage than what was prescribed. It was reported that R1 appeared very lethargic during visits. LPA reviewed R1’s Centrally Stored Medication and Destruction Log and Medication and Records (MARS) Log. During interviews, Licensee stated that she discussed concerns regarding R1’s behaviors. with R1’s responsible party. Licensee stated that R1’s Responsible Party agreed to request an assessment and increase of R1’s prescription to mitigate inappropriate and aggressive behaviors. According to the Licensee, hospice refused to increase R1’s dosage or make any changes to R1’s medication. Licensee denied that R1 was distributed any additional medications or dosages. Information obtained from R1’s record review of medication, showed that the medication given, was the medication logged and recorded when given to R1. Additional interviews conducted with staff stated that the staff follow orders on when to distribute medication to the residents. Staff stated that this is done after each distribution and initialed by the staff whom perform the task on the MARS log. (Continued on 9099-C) (Continuation from 9099) Based on LPAs observations, interviews, and record review, the allegations of staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries and staff overmedicated resident may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, a copy of this report, appeal rights was provided to the Administrator, Destiny Villalta, as evidenced by her signature.the state’s words, verbatim · CDSS document, Nov 29, 2023 · control 18-AS-20230918115254

Type of visit: Required - 1 Year

On October 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection and met with the Administrator, Destiny. The LPA introduced herself, and stated the purpose of the visit. LPA Mixson toured the facility along with the Administrator, and inspected the facility inside and outside. There were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single story home, located at 83-421 Matador Court Indio Ca 92203. Physical Plant: The facility phone number is(760) 289-6287, and is operable. The LPA observed the resident's bedroom, and it was equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean and appliances were currently operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and one fire extinguisher. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings, which were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files. Medications: were reviewed, and were locked and inaccessible to residents. The overall facility is clean, the furniture is in good condition. The home was organized and free of clutter. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for the resident at the time of this review. The dishes and utensils were sufficient in supply and stored properly. Care & Supervision: The facility has sufficient staff, one staff at the time of this visit, and no residents currently home. Records Review: The LPA reviewed one resident file, and one staff file. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, Destiny Villalta.the state’s words, verbatim · CDSS document, Oct 28, 2023