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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 05/13/2021
Date Signed: 05/24/2021 11:32:59 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/22/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201222142046
FACILITY NAME:BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)FACILITY NUMBER:
366426055
ADMINISTRATOR:MARGUERITE CROCKEMFACILITY TYPE:
740
ADDRESS:28807 BASELINE STREETTELEPHONE:
(909) 742-7353
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:115CENSUS: 60DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Marguerite Crockem, Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility staff did not administer resident's medication per physician order's
Facility staff did not clean resident's bedroom
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA identified herself and discussed the purpose of the visit with Executive Director (ED), Marguerite Crockem.

Pertaining to the allegation, "Facility staff did not administer resident's medication per physician order's," it was alleged facility staff would not administer Resident One's (R1's) medications per physician's orders, leading to the resident experiencing pain on or around December 14, 2020. ED, Crockem, denied the allegation, stating hospice personnel, responsible for R1's care, and R1's responsible parties requested more medication be administered without a physician's order. R1 could not be reached for an interview. Records review was conducted; a Progress Note, dated December 19, 2020, revealed R1 contacted emergency medical services due to experiencing severe pain. In addition, Hospice medical records revealed R1 was observed to be experiencing pain on two (2) occasions in December 2020. Records also revealed facility staff were re-educated on medication administration on five (5) occasions in December 2020. Third party interviews were
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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-20201222142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2021
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS - GENERAL: Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Based on records review and interviews the Licensee did not ensure staff were competent
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The ED stated in-service training will be provided to staff and proof will be submitted.
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to provide the services necessary to R1. Records revealed R1 was observed in pain on 2 occasions & staff were re-educated on medication administration on 5 occasions in December 2020. Interviews revealed staff weren't administering the prescribed dosage of medication to R1.
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Type B
05/20/2021
Section Cited
CCR
87303(a)
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MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on Observation, the Licensee did not ensure R1's bedroom was maintained clean at all times.
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The ED stated a plan will be developed on how to address cleaning routines in relation to pets owned by residents and will submit by POC due date.
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Photographs of R1's bedroom were obtained; report was received indicating R1's bedroom was observed to be dirty.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/22/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201222142046

FACILITY NAME:BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)FACILITY NUMBER:
366426055
ADMINISTRATOR:MARGUERITE CROCKEMFACILITY TYPE:
740
ADDRESS:28807 BASELINE STREETTELEPHONE:
(909) 742-7353
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:115CENSUS: 60DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Marguerite Crockem, Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility did not provide copy of Admission Agreement to resident's representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA identified herself and discussed the purpose of the visit with Executive Director (ED), Marguerite Crockem.

Pertaining to the allegation, "Facility did not provide copy of Admission Agreement to resident's representative," it was alleged R1's responsible party was not provided a copy of the resident's Admission Agreement on or around January 29, 2020. The ED was interviewed and reported a hard copy was provided to the responsible party upon admission. She reported a digital copy was provided on August 24, 2020, after the responsible party stated they lost the report. Records review was conducted; proof of submission of the admission agreement was found on file. Therefore, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with the ED; this report was reviewed, and a copy provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/22/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201222142046

FACILITY NAME:BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)FACILITY NUMBER:
366426055
ADMINISTRATOR:MARGUERITE CROCKEMFACILITY TYPE:
740
ADDRESS:28807 BASELINE STREETTELEPHONE:
(909) 742-7353
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:115CENSUS: 60DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Marguerite Crockem, Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility staff do not promptly respond to telephone calls
Facility staff did not regularly inform resident's representative of health changes
Facility staff did not provide adequate food service to resident
Facility staff caused injuries to resident
Facility staff are verbally abusive toward resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA identified herself and discussed the purpose of the visit with Executive Director (ED), Marguerite Crockem.

Regarding the allegation, "Facility staff do not promptly respond to telephone calls," it was alleged the facility, on or around December 17, 2020, would not answer calls or return messages from Resident One's (R1's) Responsible Parties. It was also alleged the facility would not answer calls or return messages from R1's Hospice Agency. The LPA initiated the investigation on December 31, 2020. ED, Crockem, stated R1's Responsible Parties would make continuous calls to the facility, not leave voice messages, and expect unreasonable response times. The ED also stated R1's Hospice Agency would contact the wrong telephone number at the facility, which was later resolved. Third party interviews were conducted; it was reported R1's Hospice Agency did have difficulty in making verbal contact with the facility and not having their messages returned. Records review was conducted; Communication Logs from R1's hospice agency did not note dates or
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20201222142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
VISIT DATE: 05/13/2021
NARRATIVE
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from the resident's cat. Hospice medical records revealed skin tears and bruising was observed on R1; however, no suspicion of abuse was documented. Therefore, due to lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Facility staff are verbally abusive toward resident," it was alleged facility staff would yell at and speak authoritatively to R1, causing the resident to feel belittled. R1 could not be reached for an interview. The ED was interviewed and reported having no information on the allegation. Resident interviews were conducted, and no concerns of verbal abused were reported. Therefore, due to lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with ED Crockem; this report was reviewed, and a copy provided, along with LIC 811.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20201222142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
VISIT DATE: 05/13/2021
NARRATIVE
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times of instances in which contact could not be made or when messages were left. Facility Progress Notes record multiple dates in which staff contacted one of R1's responsible parties. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Facility staff did not regularly inform resident's representative of health changes," it was alleged R1's declining health led to multiple falls in December 2020 and staff failed to report the health change to the resident's responsible party. The LPA initiated the investigation on December 31, 2020. According to ED, Crockem, R1 did sustain multiple falls, which were caused by the resident's pet cat. Crockem reported R1's responsible party refused to have the pet removed. Records review was conducted, documentation of the request was not observed on file. Staff interviews were conducted; it was reported R1's responsible parties would be notified of falls R1 sustained. Staff also reported R1's falls were caused by the pet cat. Progress Notes from December 2020 were obtained; documentation of calls to the responsible party was observed on file. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

Pertaining to the allegation, "Facility staff did not provide adequate food service to resident," it was alleged R1 would be served small meal portions and, on occasion, staff would forget to deliver food resulting in R1 going without a meal. ED, Crockem, stated she had no information on the allegation. R1 could not be reached for an interview. A records review was conducted; a Comprehensive Nursing Assessment from Hospice, dated December 14, 2020, revealed R1 gained three (3) pounds since their admission, in January 2020. Staff and resident interviews were conducted; it was reported R1 would regularly receive meals and did not make complaints about not receiving enough food. It was also reported by residents there are no concerns with food service at the facility. Therefore, based on a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Facility staff caused injuries to resident," it was alleged R1 sustained a skin tear, in or around April 2020, due to an unknown staff member hastily zipping up compression stockings on the resident. It was also alleged R1 sustained bruises, in or around May 2020, due to being aggressively handled when given bathes. R1 was not available to be interviewed. The ED was interviewed and reported R1 did utilize compression stockings; however, she indicated the only injuries R1 sustained were due to the resident's pet cat scratching their legs. The ED denied R1 sustained injuries due to staff abuse. Staff assigned to care for R1 were interviewed; no suspicions of or known abuse was reported. Interviews reported skin tears and bruises were observed on the resident; the injuries were believed to be caused by falls and scratches
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20201222142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
VISIT DATE: 05/13/2021
NARRATIVE
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conducted; it was reported R1 was observed to be in pain and facility staff were not administering the needed dosages of medication to R1. Furthermore, the facility eMAR indicated one (1) medication appeared not to have been administered on December 17, 2020 and December 18, 2020. Therefore, based on records review, this allegation is deemed SUBSTANTIATED.

Regarding the allegation, "Facility staff did not clean resident's bedroom," it was alleged the litter box of the cat belonging to R1 was observed on December 07, 2020 to be overflowing in the resident's bedroom and the room was dusty and dirty. R1 could not be reached for an interview. Photographs of R1's bedroom were obtained. Staff interviews reported the kitty litter was cleaned out regularly and room maintained clean. Third party interviews were conducted; one (1) report was received indicating R1's bedroom was observed to be dirty. Therefore, based on photographs and interview, this allegation is deemed SUBSTANTIATED.

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 with ED Crockem; this report was reviewed, and a copy provided, along with LIC 811 and Appeal Rights.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7