336426550-10-22-2025-18-AS-RORN-DMWQ48-20251029114955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426550
Report Date: 10/22/2025
Date Signed: 10/22/2025 02:50:34 PM

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
05/24/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20220524154716

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:	10/22/2025
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:			TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not respond to emergency call button in a timely manner.
Facility staff did not seek medical attention in a timely manner.
Staff did not safeguard resident's personal belongs.
Resident did not receive medications as prescribed.

INVESTIGATION FINDINGS:

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On 10/22/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a follow-up investigation to determine the findings.

The investigation involved the following steps: On 06/02/2022, Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced at the facility to begin an investigation into the allegations listed above. LPA met with Executive Director Heather Scott and explained the purpose of the visit. During today's visit, LPA interviewed three (3) staff members and five (5) residents and reviewed and obtained photographic copies of relevant records related to Resident #1 (R1).

On 10/22/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a follow-up investigation and attempted to interview the reporting party multiple times. However, the LPA was unable to interview the reporting party and left no voicemail because the mailbox was full. LPA attempted to interview the Ombudsman's name in the report. LPA was unable because the Ombudsman is no longer with the agency.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

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 5

Control Number 18-AS-20220524154716

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: 10/22/2025

NARRATIVE

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Allegation #1: Staff did not respond to emergency call button in a timely manner.

The complaint alleged that on 04/26/2022, at approximately midnight, the resident (R1) pulled the emergency string, but the alarm could not be heard down the hall. On 10/22/2025, LPA Richard reviewed the records of LPA Tricia Danielson interviewing three staff members #1-3 (S1-S3). All stated that the alarm system had been upgraded a week earlier and was functioning properly. Records showed that the LPA sounded the alarm, and staff arrived within 2 minutes. On 10/22/2025, LPA Richard reviewed the records of LPA Danielson's interview with five residents #1-5 (R1-R5). Two out of five confirmed the allegations. The LPA Danielson reviewed the facility alarm response records; no string was pulled from R1's room. A review of the LPA records indicated that the Ombudsman confirmed the facility reported to them that the alarm system was working correctly.

Based on observation, interviews, and record reviews, the preponderance of evidence has not been met. Although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; thus, the allegation is unsubstantiated.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20220524154716

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: 10/22/2025

NARRATIVE

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Allegation #2: Facility staff did not seek medical attention in a timely manner.

The complaint alleged that on 04/26/2022, around midnight, R1 began experiencing nausea and shakiness and was going in and out of consciousness. R1 pulled the emergency string, but the alarm could not be heard. R1 had to call R1's neighbor to get help. On 10/22/2025, LPA Richard reviewed LPA Danielson’s records, which showed that LPA Danielson interviewed three staff members, #1-3 (S1-S3). All three denied the allegation. S1 stated that when the residents told S2 that R1 was having a medical emergency, S2 immediately called 911, and R1 was taken to the hospital. S1 also said that the two emergency strings in R1’s room and bathroom were working when S2 arrived. On 10/22/2025, LPA Richard examined LPA Danielson's interviews with five residents, #1-5 (R1-R5). Two of the five confirmed the allegations and said that 911 did take R1 to the hospital.

Based on observation, interviews, and record reviews, the preponderance of evidence has not been met. Although the allegation may have happened or be valid, there is not enough evidence to determine whether the alleged violation occurred; therefore, the allegation is unsubstantiated.

Allegation #3: Staff did not safeguard the president’s personal belongings.

The complaint alleged that after resident R1 was admitted to the hospital, R1 was discharged on May 17, 2022, and returned to the facility. Upon returning, R1 discovered that their room had been ransacked and that several items, including clothing, bed sheets, and dog grooming equipment, were missing.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20220524154716

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: 10/22/2025

NARRATIVE

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On October 22, 2025, LPA Richard reviewed the records of LPA Danielson, which showed that Danielson had interviewed three staff members (S1-S3). All three denied the allegations. Staff member S3 mentioned that when residents are in the hospital, facility staff make sure rooms are locked. S3 also suggested that R1 might have been confused about the missing items. Additionally, on October 22, 2025, LPA Richard examined the records of LPA Danielson's interviews with five residents (R1-R5). One resident, confirmed the allegations, and that some of R1's missing items were eventually returned to R1's room.

Allegation #4: Resident did not receive medications as prescribed.

The complaint alleged that three to five days after discharge, R1's medications were not filled until 05/23/22.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20220524154716

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: 10/22/2025

NARRATIVE

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Additionally, on October 22, 2025, LPA Richard examined the records of LPA Danielson's interviews with five residents (R1-R5). One resident confirmed the allegations, that some of R1's medication was not refilled three days after discharge from the hospital. S2 explained to R1 that some of their medications were not refilled after discharge from the hospital because R1 refused to see the old MD.

Based on the interviews and record reviews, the preponderance of evidence has not been met. Although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; thus, the allegation is unsubstantiated.

This facility is closed on 05/08/2025.

No deficiencies cited.

A copy of the report will be mailed to the last known address: 23 Corporate Plaza Dr., Ste. 150, Newport Beach, CA 92660.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

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