331880722-6-6-2025-18-AS-APAO-DHPKVF-20250616081412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880722
Report Date: 06/06/2025
Date Signed: 06/06/2025 06:59:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2022 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220321154449

FACILITY NAME:	DESERT HILLS MEMORY CARE CENTER		FACILITY NUMBER:	331880722
ADMINISTRATOR:	HUDSON, CHANTELLE		FACILITY TYPE:	740
ADDRESS:	25818 COLUMBIA ST		TELEPHONE:	(951) 652-1837
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	58	CENSUS: 32	DATE:	06/06/2025
		UNANNOUNCED	TIME BEGAN:	03:23 PM
MET WITH:	LICENSEE, SHANNON MOORE		TIME COMPLETED:	04:18 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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On May 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Licensee, Shannon Moore. LPA explained the reason for the visit was to provide findings for the complaint investigation.
On March 21, 2022, Community Care Licensing received a complaint alleging, Resident sustained injuries while in care,Staff handled resident in a rough manner, Staff are overdosing resident, Staff left resident in soiled clothing for extended period of time, and staff did not safeguarded residents personal belongings. During the investigation LPA conducted interviews, record reviews, and made observations.
Regarding the allegation Resident sustained injuries while in care, it was reported R1 sustained a serious knee injury. It was also reported that R1’s knee was swollen and R1 was unable to move it. Information obtained from interview with Executive Director, Chantelle Hudson advised R1 had no falls and injuries reported during placement. Executive Director indicated R1 was placed for 30-day respite care. Interviews with additional staff indicated there were no bruises observed. Additional information obtained from interviews with staff stated R1 did not have any falls due to R1 being “total assist” with a Hoyer lift for transferring. It was further stated a hospice nurse would visit the facility two to three times per week and a representative from a home health agency would come once or twice a week. Additional information obtained from interviews with hospice nurse stated body checks of R1 was conducted and no bruises were observed. Interviews with additional residents indicated there no concerns with obtaining any injuries while in care. LPA’s record review confirmed there were no new injuries obtained during R1’s placement. Records reviewed included a “Daily Skin Checks” log, and Hospice Nurse Sign In Sheet. The review of records confirmed the last skin check was conducted with Hospice Nurse and R1’s Responsible Party and was signed off that there were no concerns.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220321154449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT HILLS MEMORY CARE CENTER	FACILITY NUMBER: 331880722
	VISIT DATE: 06/06/2025

NARRATIVE

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Regarding the allegation Staff handled resident in a rough manner, it was reported two unidentified women smashed R1 into the wall and caused a knee injury. Administrator denied this allegation. Information obtained from interview with Administrator advised R1 did not advise that facility staff handled R1 in a rough manner. Additionally, Administrator stated R1 was aggressive and abrasive towards staff. Information obtained from staff interviews denied they were rough with R1 or observed other staff being rough with R1. Information obtained from interviews with residents indicated there has not been a time when staff has handled them in a rough manner and they have not seen any staff miss handle any other residents. A review of the records did not document there were any disciplinary actions regarding personal rights violations.

Regarding the allegation staff are overdosing resident, it was reported R1 had a prescription of a specific medication since 2021 and only 60 pills were given over the course of several months, but the facility managed to give R1 60 pills in a matter of 15-30 days. Wellness Director, Shannon Moore denied this allegation and stated that the medication was distributed as prescribed by R1’s Physician’s orders. Information obtained from interviews with staff stated medication was given as ordered. Staff also stated that R1’s medications were not re-evaluated during the 30-day respite stay. Information obtained from interview with Hospice Nurse indicated there were no concerns brought to the attention of the hospice team regarding R1’s medication. A review of the records, which included R1’s Medication Administration Record (MAR), and R1’s centrally stored medication report, indicated that the medication was provided to R1 as prescribed.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220321154449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT HILLS MEMORY CARE CENTER	FACILITY NUMBER: 331880722
	VISIT DATE: 06/06/2025

NARRATIVE

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Regarding the allegation staff left resident in soiled clothing for extended period of time, it was reported that R1 was observed to be covered in feces. Executive Director denied this allegation and stated R1 was never left in soiled clothing for extended periods of time. Additional information indicated R1 was able to communicate and share when they needed to be changed. Information obtained from interview with additional staff indicated R1 was not ever covered in feces or left in soiled clothing for an extended amount of time. Staff advised the facility has a changing schedule, which would occur every 1.5 to 2 hours. Information obtained from interview with Hospice Nurse stated R1 was not observed to be covered in feces and did not mention to staff that there were any issues or concerns with linen or garments being changed in timely manner.

Regarding the allegation staff did not safeguard resident’s personal belongings. It was reported R1’s necklace was missing for 72 hours. Information obtained from interview with Wellness Director stated the necklace was reported missing, but was found. It was advised that R1’s responsible party received and signed for the items. No further details were provided regarding where the necklace located. LPA’s review of Resident Personal Property and Valuables Report, along with a photo copy, and signed document indicating the item was removed from the facility. Interviews with additional staff corroborated the information. Interviews with additional residents indicated there are no concerns with their items being safeguarded.

Based on interviews, record reviews, and observations, regarding the allegations that resident sustained injuries while in care, staff handled resident in a rough manner, staff are overdosing resident, staff left resident in soiled clothing for extended period of time, and staff did not safeguard resident’s personal belongings are unsubstantiated. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur due to the inability to interview R1.

An exit interview was conducted. A copy of this report was provided to Administrator, Shannon Moore.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC9099 (FAS) - (06/04)

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