Desert Cottage II.

Licensing Program Analyst (LPA) Glenn Trueman and conducted an announced visit to the facility to conduct an interview with Resident One (R1) regarding an open complaint unrelated to this facility. LPA met with Elizabeth Hengstler, licensee, who was informed of the purpose for the visit. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Elizabeth Hengstler.

Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Aziz Faizi conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPAs met with Caregiver Teri Duet and explained the purpose of the visit. Licensee Elizabeth Hengstler joined the visit at a later time. During the visit, LPAs toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to conduct a health and safety check and to deliver amended complaint investigation report dated 12-03-2025. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. LPA did not observe any health and safety concerns. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Caregiver Teri Duet and explained the purpose of the visit. Licensee Elizabeth joined the visit at a later time. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Caregiver Teri Duet.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During the visit, LPA toured the facility and no immediate health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of this report was provided Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Teri Duet and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Caregiver Teri Duet.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection . The LPA was greeted by Caregiver Terri Duet, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Licensee Elizabeth Hengstler joined the visit at a later time. Facility Overview: The facility is a single- story building with 3 residents' bedrooms, 1 staff room, 3 bathrooms, a dinning room, a living room, an office area, a kitchen, a laundry room, an outdoor area, and a garage. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents in care. The smoke detectors and carbon monoxide detectors were operable. LPA observed fire extinguisher to be in compliance with the department's requirements and with an expiration date of 04-02-2026. The water temperature was tested within regulations measuring 105.9 F Continued 809-C...... 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 Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 12-25-2026 and CPR certification with the expiration date of 01-15-27. Record Review and Resident/Staff Files: LPA reviewed files for 2 staff members, confirming criminal clearance, updated training, and health screening. 2 residents' files were reviewed and contained all required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the Kitchen area. LPA reviewed medications for 1 resident confirming that all medication were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 10-03-2025, which met the department's requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Licensee Elizabeth Hengstler.

LPA’s file review indicated R1 was admitted to the facility in April 2023, placed under hospice care in August 2023, and moved out on 12-06-2023 to another facility. R1 passed away in September 2024. R1 was the only resident at the time of the alleged abuse. During the investigation, LPA interviewed R1’s relevant party, who relayed a disturbing account allegedly shared by R1 that S1 had dragged R1 across the floor from the bathroom to the bed, forcefully thrown R1 onto the bed, and slapped R1 multiple times after a fall near the toilet. LPA attempted to interview two (2) staff members from the hospice agency, but it was unsuccessful. R1 had a roommate, but that person passed away in October 2023, so no interview was conducted. LPA conducted interview with two (2) staff members including S1, both of whom denied the alleged physical abuse took place. LPA learned there was a police report generated from an incident that occurred on 11-25-2023 related to R1. LPA obtained and reviewed the police report from Indio Police Department. The information obtained from the police report did not contain supportive evidence to corroborate the allegation. Based on records review and interviews conducted, the allegation that staff physically abused resident in care is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Licensee Elizabeth Hengstler and explained the purpose of the visit. During today's visit, LPA toured the facility and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Terri Duet, informed them of the purpose of the visit and was granted access. Licensee Elizabeth Hengstler arrived at a later time. During today's visit, LPA toured the facility, obtained pertinent documentation and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Licensee Elizabeth Hengstler.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Caregiver Terri Duet, informed them of the purpose of the visit and was granted access. During today's visit, LPA toured the facility, obtained pertinent documentation and conducted interviews. No immediate health and safety concerns were observed. An exit interview was conducted and a copy of this report was provided to Caregiver Terry Duet.

On 8/27/2025, Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez arrived unannounced to the facility to conduct a case management visit to deliver an Immediate Exclusion order for Staff, Destiny Villalta. LPAs were greeted and granted entry by Licensee/Administrator Elizabeth Hengstler who was informed of the purpose of the visit. During today's visit, LPAs toured the facility’s interior and exterior with Licensee/Administrator Elizabeth Hengstler and collected pertinent documentation. LPAs provided Caregiver Destiny Villalta with the Immediate Exclusion order dated 8/27/2025 and LPAs observed Destiny Villalta leave the premises after issuance of the letter. No citations were issued during today’s visit. An exit interview was conducted, and this report was reviewed and a copy was provided to Licensee/Administrator Elizabeth Hengstler .

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding complaint control numbers 18-AS-20240408110606 and 18-AS-20241210103507. LPA met with Destiny Villalta, Administrator, who allowed LPA entry. LPA toured the inside and outside of the facility. LPAs conducted interviews with staff and residents. LPA obtained pertinent documents from the Administrator. LPA did not observe any health and safety concerns at this time of visit There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report were provided.

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report received on 12-06-2023. LPA met with Destiny Villalta, Administrator, who allowed LPA entry. LPA toured the inside and outside of the facility. LPAs conducted interviews with staff and resident. LPA obtained pertinent documents from the Administrator. LPA did not observe any health and safety concerns at this time of visit There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report were provided.

Licensing Program Analysts (LPA) Seo Jeon and Janette Romero made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report #18-AS-20241203161122. LPA met with Destiny Villalta, Administrator, who allowed LPA entry. LPA toured the inside and outside of the facility. LPAs conducted interviews with staff and residents. LPAs obtained pertinent documents from the Administrator. LPAs did not observe any health and safety concerns at this time of visit There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report were provided.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility for a health and safety check. LPA met with Administrator Destiny Villalta, identified himself and discussed the purpose of the visit. A tour of the facility was conducted. No immediate health and safety concerns were observed during the visit. During today’s visit, LPA interviewed residents and staff and conducted records review. LPA verified facility does not have bedridden residents. An exit interview was conducted, and a copy of this report was provided to Administrator Destiny Villalta

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a case management. The LPA met with Facility Administrator Destiny Villalta, and informed her of the purpose for the visit and were granted access. The facility is a single story building and consists of three(3) resident rooms, one(1) staff room and three (3) bathrooms. The LPA obtained copies of relevant documentation such as the LIC 500 Personnel Report and client roster. LPAs observed current personnel to be fingerprint cleared and listed on the facility's personnel report. There is currently one (1) resident in care. LPA's case management included interview with management and resident, obtaining relevant documentation and conducting a tour of the facility for a health and safety check. No health and safety concern were observed during today's visit. Further review is needed at this time. Possible visits and phone interviews will be conducted before a decision is rendered. An exit interview was conducted, and a copy of this report was provided to Administrator Destiny Villalta.

Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection . The LPAs were greeted by licensee Elizabeth Hengstler, notified her of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with 4 bedrooms and 3 bathrooms. There is no gated pool and there are no firearms on the premises. Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were tested and were operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 12/2025. LPAs observed the hot water temperature to meet requirements at 109.1°F. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of December 25 th , 2024. Continued on LIC809-C..... 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 Record Review and Resident/Staff Files: LPAs reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. One resident's file was reviewed and contained all required documentation. LPA's observed Staff, resident files, first aid kit were locked in a cabinet in the kitchen, and PPE's, emergency food and water were stored in the garage. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked located in the kitchen cabinets.. Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 7-1-2024, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Elizabeth Hengstler

(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. 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) 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.

On October 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection and met with the Administrator, Destiny. The LPA introduced herself, and stated the purpose of the visit. LPA Mixson toured the facility along with the Administrator, and inspected the facility inside and outside. There were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single story home, located at 83-421 Matador Court Indio Ca 92203. Physical Plant: The facility phone number is(760) 289-6287, and is operable. The LPA observed the resident's bedroom, and it was equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean and appliances were currently operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and one fire extinguisher. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings, which were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files. Medications : were reviewed, and were locked and inaccessible to residents. The overall facility is clean, the furniture is in good condition. The home was organized and free of clutter. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for the resident at the time of this review. The dishes and utensils were sufficient in supply and stored properly. Care & Supervision : The facility has sufficient staff, one staff at the time of this visit, and no residents currently home. Records Review: The LPA reviewed one resident file, and one staff file. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, Destiny Villalta.