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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426550
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:30:11 PM

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
12/06/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231206160251
FACILITY NAME:DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGSFACILITY NUMBER:
336426550
ADMINISTRATOR:HEATHER SCOTTFACILITY TYPE:
740
ADDRESS:13660 MOUNTAIN VIEW ROADTELEPHONE:
(760) 671-7820
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:56CENSUS: 53DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Heather Scott, AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility staff mismanages resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced initial complaint visit to the above noted facility. LPA met with the Administrator Heather Scott and informed them of the purpose of this visit. During this investigation, LPA conducted a tour of the physical plant, conducted interviews with staff, residents, and received supportive documentation for review. The following was determined.

Allegation # 1, Facility staff mismanages resident's medication. Concerns were expressed that a resident has not had their medications, (M1, M2, and M3) for weeks while at the facility. LPA conducted a staff interview, resident interviews, and record review of the Medication Administration Record (MAR).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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
Control Number 18-AS-20231206160251
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 COVE ASSISTED LIVING AT DESERT HOT SPRINGS
FACILITY NUMBER: 336426550
VISIT DATE: 12/12/2023
NARRATIVE
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Record review found that M1 was ordered by the facility on 11/14/23, and last administered to R1 on 11/23/23 at 2:00pm. During the visit, staff found that the medication was denied by the physician on 10/20/23. As a result, R1 did not have their medication refilled until 12/4/23. M2 was ordered 11/24/23, and last administered by the facility on 12/1/23. R1 remains to be out of M2 until R1 sees a doctor for a refill. M3 was found to be administered on an as needed basis as ordered by R1's physician. Resident interviews revealed that medications are managed to provide for resident's needs. Based on record review, and staff interview, the regulatory requirement to assist residents with self-administered medications as needed was not met, and this allegation was Substantiated as a result.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report, along with copies of the LIC9099, LIC9099D, LIC811, and Appeal Rights were provided.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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
12/06/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231206160251

FACILITY NAME:DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGSFACILITY NUMBER:
336426550
ADMINISTRATOR:HEATHER SCOTTFACILITY TYPE:
740
ADDRESS:13660 MOUNTAIN VIEW ROADTELEPHONE:
(760) 671-7820
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:56CENSUS: 53DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Heather Scott, AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner made an unannounced initial complaint visit to the above noted facility. LPA met with the Administrator Heather Scott and informed them of the purpose of this visit. During this investigation LPA conducted a tour of the physical plant, conducted interviews with staff, residents, and requested supportive documentation for review. The following was determined.

Allegation # 1, Facility staff did not administer resident's medication as prescribed. Concerns were expressed that a resident has not had their medications, (M1, M2, and M3) for weeks while at the facility. LPA conducted a staff and resident interviews, and a record review of the Medication Administration Record (MAR) for the months of 11/2023, and 12/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20231206160251
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 COVE ASSISTED LIVING AT DESERT HOT SPRINGS
FACILITY NUMBER: 336426550
VISIT DATE: 12/12/2023
NARRATIVE
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LPA discovered that M1, and M2 were ordered to be taken daily, and M3 was found to be a medication to be taken as needed. Per the MAR, and LPA's observation of the pill count, R1 was given M3 on 12/1/23, and 12/2/23. Based on LPA's observation and record review, the facility was administering M1, M2, and M3 as ordered by R1's physician. This allegation was Unsubstantiated as a result.

A finding of UNSUBSTANTIATED means that 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.


An exit interview was conducted where a copy of this report along with a copy of the LIC811, was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20231206160251
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 COVE ASSISTED LIVING AT DESERT HOT SPRINGS
FACILITY NUMBER: 336426550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training to staff regarding the cited regulation, and provide proof of such by POC date.
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LPA conducted record review, and found that R1 was out of M1 from 11/23/23 - 12/4/23. This is a potential health and safety or personal rights 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5