Complaint Investigation Report

336413271-9-19-2025-18-AS-APAO-DLTP3V-20250924105811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

RIVERSIDE ASC , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

09/22/2023 and conducted by Evaluator Janette Romero

COMPLAINT CONTROL NUMBER: 18-AS-20230922152416

Due to staff neglect, resident had multiple unexplained bruises

Staff did not notify authorized representative of incidents

Staff increased medication without authorization

On 09/19/2025, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced visit to the facility to deliver an amended version of the original report regarding the allegations listed above. LPA met with Licensee, Elizabeth Hengstler who was informed of the purpose of the visit.

The alleged victim has been identified as Resident 1 (R1). Licensee Hengstler reported R1 never resided in this facility. LPA contacted R1’s responsible person who confirmed R1 never resided in this facility. LPA reviewed R1’s admission agreement signed and dated 08/30/2023, noting the agreement is with a different facility located at a different address. Therefore, the allegations noted above are unfounded. Unfounded means the allegations are false, could not have happened and/or are without a reasonable basis. The Department has opened a complaint at the facility R1 resided at to investigate the allegations. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Licensee Hengstler.