336423672-11-29-2023-18-AS-JDHS-CY3R5P-20231130114328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423672
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:35:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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
09/18/2023 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20230918115254

FACILITY NAME:	DESERT COTTAGE II		FACILITY NUMBER:	336423672
ADMINISTRATOR:	ELIZABETH HENGSTLER		FACILITY TYPE:	740
ADDRESS:	83-421 MATADOR COURT		TELEPHONE:	(760) 342-7767
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY:	6	CENSUS: 2	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator, Destiny Villalata		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

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

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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
09/18/2023 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20230918115254

FACILITY NAME:	DESERT COTTAGE II		FACILITY NUMBER:	336423672
ADMINISTRATOR:	ELIZABETH HENGSTLER		FACILITY TYPE:	740
ADDRESS:	83-421 MATADOR COURT		TELEPHONE:	(760) 342-7767
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY:	6	CENSUS: 2	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator,		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not properly keep records of medication being dispensed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.

On 09/18/2023, Community Care Licensing received a complaint stating that staff did not properly keep records of medication being dispensed. During a visit to the facility on 11/07/2023, Licensee provided R1’s Centrally Stored Medication and Destruction Logs and Medication Administration Records (MARs). After review, it appeared that all medications R1 was being distributed during placement, were properly logged and documented. All entries were dated and signed by facility staff. Licensee stated that medications are logged and initialed by staff administrating the medication. Additional interviews with staff stated that they initial the MARS when medication is distributed to the residents. According to R1’s hospice agency, the facility was keeping required and accurate information of the R1’s distribution of medication. No concerns were advised.

(Continued on 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20230918115254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT COTTAGE II	FACILITY NUMBER: 336423672
	VISIT DATE: 11/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(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.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20230918115254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT COTTAGE II	FACILITY NUMBER: 336423672
	VISIT DATE: 11/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(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)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20230918115254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT COTTAGE II	FACILITY NUMBER: 336423672
	VISIT DATE: 11/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(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.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5