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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413271
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:46:42 PM


Document Has Been Signed on 08/21/2024 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 5DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Elizabeth HengstlerTIME COMPLETED:
01:00 PM
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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.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/13/2024 09:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 09:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Limitations -Capacity and Ambulatory Status
Deficient Practice Statement
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The original form LIC809D was generated in error after LPA closed the care tool and final printed the LIC809. No deficiencies were observed and no corrections were needed from the facility.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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