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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423672
Report Date: 11/26/2024
Date Signed: 11/26/2024 10:51:11 AM

Substantiated


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
02/19/2020 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200219153407
FACILITY NAME:DESERT COTTAGE IIFACILITY NUMBER:
336423672
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-421 MATADOR COURTTELEPHONE:
(760) 289-6287
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 1DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
10:00 PM
MET WITH:Destiny Villalta, AdministratorTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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Neglect/lack of care and supervision resulting in Resident #1 (R1) sustaining unexplained injuries.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 5
Control Number 18-AS-20200219153407
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 II
FACILITY NUMBER: 336423672
VISIT DATE: 11/26/2024
NARRATIVE
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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.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200219153407
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 II
FACILITY NUMBER: 336423672
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited
CCR
87468.2
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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.
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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
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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.
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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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/19/2020 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200219153407

FACILITY NAME:DESERT COTTAGE IIFACILITY NUMBER:
336423672
ADMINISTRATOR:ELIZABETH HENGSTLERFACILITY TYPE:
740
ADDRESS:83-421 MATADOR COURTTELEPHONE:
(760) 289-6287
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 1DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
10:00 PM
MET WITH:Destiny Villalta, AdministratorTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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Staff caused injury to Resident #1 (R1)
INVESTIGATION FINDINGS:
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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 Administrator Destiny Villalta to discuss the findings.

On February 19, 2020, the Department received a complaint with allegation that facility staff caused injuries to R1. The Department’s investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

According to information received, it was alleged that R1 was physically abused by staff and as a result, sustained injuries. Injuries observed by pertinent individuals included 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. Investigation revealed that prior to injuries observed, R1 was at the facility. As determined, the injuries were sustained at facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200219153407
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 II
FACILITY NUMBER: 336423672
VISIT DATE: 11/26/2024
NARRATIVE
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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 Villalta

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5