336426550-12-31-2025-18-AS-CTUA-DPVSLK-20251231125828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426550
Report Date: 12/31/2025
Date Signed: 12/31/2025 10:51:45 AM

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
03/15/2024 and conducted by Evaluator Janette Romero

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240315133014

FACILITY NAME:	DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGS		FACILITY NUMBER:	336426550
ADMINISTRATOR:	HEATHER SCOTT		FACILITY TYPE:	740
ADDRESS:	13660 MOUNTAIN VIEW ROAD		TELEPHONE:	(760) 671-7820
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	0	CENSUS: 0	DATE:	12/31/2025
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:			TIME COMPLETED:	08:57 AM

ALLEGATION(S):

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Staff retaliate against residents.
Staff do not ensure residents’ needs are being met.
Staff do not provide residents with adequate personal care supplies.
Staff do not provide adequate food service to residents.
Staff do not ensure temperature of water for resident use is appropriate.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

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 7

Control Number 18-AS-20240315133014

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: 12/31/2025

NARRATIVE

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Regarding the allegation, “Staff retaliate against residents” it was alleged that the Executive Director (ED) uses foul language when speaking with the residents. It was further alleged the ED retaliates against any resident who reports to an outside agency. Administrator Scott was interviewed and reported they have been the ED for approximately the past seven (7) years and refuted the allegations. Five (5) of five (5) residents interviewed reported that Administrator Scott has never used foul language towards them or in their presence. Three (3) of four (4) residents interviewed reported they have communicated with outside agencies and have not faced retaliation from Administrator Scott or any other facility staff. The remaining one (1) of four (4) residents interviewed stated they have not reported to an outside agency but do not fear they would be retaliated against if they raised any concerns. Two (2) of two (2) staff were interviewed and reported they have never witnessed Administrator Scott or any other facility staff use foul language towards any of the residents or retaliate against them in any form.

Regarding the allegation, “Staff do not ensure residents’ needs are being met” it was alleged that residents do not receive showers. It was further alleged that the facility is short-staffed. One (1) of five (5) residents reported they have the capacity to independently shower and do not require shower assistance from staff. The remaining four (4) of five (5) residents interviewed reported they have always received showers on their scheduled days, which is approximately two-to-three times per week. Four (4) of four (4) residents interviewed reported they feel their basic needs have been met while residing in the facility. Two (2) of two (2) staff interviewed reported residents are showered on their scheduled days and they do not feel the facility is understaffed.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 18-AS-20240315133014

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: 12/31/2025

NARRATIVE

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Regarding the allegation, “Staff do not provide adequate food service to residents” it was alleged that residents are not receiving fresh fruits and vegetables. It was further alleged that the food quality and quantity is poor, the facility serves spaghetti multiple nights in a row and sandwiches often and frequently runs out of milk. Five (5) of five (5) residents interviewed refuted the allegations and reported the following information. The facility follows their food menu and serves a variety of foods which include fresh fruits and vegetables. The facility serves quality food, and the meals are well portioned. Residents do not have knowledge of the facility running out of milk and alternative food options are available at every meal upon request. LPA toured the facility and observed the facility to have food including milk, fresh fruits, and vegetables available for the residents. LPA also reviewed a menu from March 2024 which did not list spaghetti multiple nights in a row. A different sandwich was offered daily for lunch. However, the menu reflects a signature next to the “Dietitian’s Signature” section and the menu states, “Milk offered at every meal”. LPA also reviewed an “A la Carte” menu of alternative menu options that are always available. Two (2) of two (2) staff interviewed corroborated the information provided by the residents.

Regarding the allegation, “Staff do not ensure temperature of water for resident use is appropriate” it was alleged that the water is scalding hot. Four (4) of four (4) residents interviewed reported having access to hot and cold water at the facility and having the ability, or requesting staff assistance, to adjust the water temperature to their liking. One (1) of four (4) residents interviewed reported they have accidentally only turned on the hot water in their bathroom faucet thinking it was the cold water and did not get burned nor did they feel the water was scalding hot. LPA measured the hot water temperature in three (3) resident bathrooms and found it to meet regulatory requirements. Two (2) of two (2) staff were interviewed and reported residents who are cognizant have the mental capacity to adjust the water temperature to their liking. However, caregivers test the water temperature on their arms before allowing a resident requiring assistance, to touch the water. Two (2) of two (2) staff interviewed reported they observe for any nonverbal cues that would indicate whether the resident is uncomfortable with the hot water temperature such as immediately removing their hand from the water, redness on their hand, or becoming agitated. If the resident seems comfortable with the water temperature, care staff will proceed to assist the resident with the shower.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 18-AS-20240315133014

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: 12/31/2025

NARRATIVE

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Regarding the allegation, “Staff do not provide residents with adequate personal care supplies” it was alleged that residents do not have access to toilet paper and Kleenex facial tissues at night as they are locked in a cabinet. Five (5) of five (5) residents were interviewed and reported housekeeping staff provide them with personal hygiene supplies when requested. Five (5) of five (5) residents interviewed reported they always have access to toilet paper and each time they have requested additional rolls of toilet paper, they have received it. Three (3) of four (4) residents interviewed reported they have not needed nor requested Kleenex from the facility and use toilet paper as facial tissues. One (1) of four (4) residents interviewed reported they chose to purchase their own Kleenex and have never asked if the facility provides it. Two (2) of two (2) staff interviewed reported a supply of toilet paper is stored in the laundry room and accessible to staff at all times. One (1) of two (2) staff interviewed reported Kleenex is also available for the residents upon request.

Although the allegations may have happened or are valid, the preponderance of evidence standard was not met to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. Due to the facility’s closure, LPA was unable to conduct an exit interview. On behalf of Licensing Program Analyst (LPA) Janette Romero, this report was mailed by the Riverside Regional Office support staff to the ex-licensee’s last known mailing address via USPS certified mail, to communicate the findings related to the above-mentioned allegations. The facility has been closed since 05/08/2025.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
03/15/2024 and conducted by Evaluator Janette Romero

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240315133014

FACILITY NAME:	DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGS		FACILITY NUMBER:	336426550
ADMINISTRATOR:	HEATHER SCOTT		FACILITY TYPE:	740
ADDRESS:	13660 MOUNTAIN VIEW ROAD		TELEPHONE:	(760) 671-7820
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	0	CENSUS: 0	DATE:	12/31/2025
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:			TIME COMPLETED:	08:57 AM

ALLEGATION(S):

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Staff mismanage residents’ medications.

INVESTIGATION FINDINGS:

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On behalf of Licensing Program Analyst (LPA) Janette Romero, this report was mailed to the ex-licensee’s last known mailing address via USPS certified mail, to communicate the findings related to the above-mentioned allegations. The facility has been closed since 05/08/2025.

Regarding the allegation, “Staff mismanage residents’ medications” it was alleged that residents’ medications kept running out, residents were given the incorrect medication and Pro-Re-Nata (PRN) medication was not available at night. One (1) out of the four (4) residents disclosed that the wrong medication was given to them. The resident was able to account which medication should have been provided due to recognizing the pill. This resident refused the medication and brought it to the attention of staff. This same resident reported asking for Pro-Re-Nata (PRN) medication. It was reported they asked for the medication at 10am and did not receive the medication until 2pm when they had to ask for it again. Two (2) of four (4) residents interviewed reported that although they experienced a medication refill delay in the past, the medication refills were received prior to finishing their current supply therefore they did not miss any medication doses.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 18-AS-20240315133014

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: 12/31/2025

NARRATIVE

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The remaining two (2) of four (4) residents interviewed reported they have not experienced any medication refill delays while residing in the facility. An additional, four (4) of four (4) residents interviewed reported they have never received the incorrect medication and have not experienced issues receiving PRN medications at night. Two (2) of two (2) staff interviewed reported they did not have knowledge of any residents being administered the incorrect medications or missing doses because the facility ran out of their medications. Two (2) of two (2) staff interviewed reported residents’ medications are centrally stored in the locked medication room and PRN medications are available for the residents upon request at any time of day. Administrator Scott reported that residents can use their bell call, personal cell phone, or pull cord in the bathroom to call a medication technician and request PRN medications at any time of day.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D. On behalf of Licensing Program Analyst (LPA) Janette Romero, this report was mailed by the Riverside Regional Office support staff to the ex-licensee’s last known mailing address via USPS certified mail, to communicate the findings related to the above-mentioned allegations. The facility has been closed since 05/08/2025.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 18-AS-20240315133014

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: 12/31/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/31/2025 Section Cited CCR 87564(a)(4)	1 2 3 4 5 6 7	(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 met as evidenced by:	1 2 3 4 5 6 7	Due to the facility's closure on 05/08/2025, LPA was unable to conduct an exit interview with licensee to develop the plan of correction.
	8 9 10 11 12 13 14	One (1) out of the four (4) residents disclosed that the wrong medication was given to them. This same resident reported asking for PRN medication at 10am and not receiving it until 2pm when they had to ask for it again. This posed a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 7