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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413271
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:05:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2024 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240411143908
FACILITY NAME:DESERT COTTAGEFACILITY NUMBER:
336413271
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-617 HIMILAYA DRIVETELEPHONE:
(760) 342-7767
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 6DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Elizabeth Hengstler, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are chemically restraining residents in care.
Staff are physically restraining residents in care.
Food services are inadequate.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20240411143908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DESERT COTTAGE
FACILITY NUMBER: 336413271
VISIT DATE: 08/21/2025
NARRATIVE
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(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.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
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