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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426055
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:23:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:MARGUERITE CROCKEMFACILITY TYPE:
740
ADDRESS:28807 BASELINE STREETTELEPHONE:
(909) 742-7353
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:115CENSUS: 67DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Marguerite CrockemTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Pauline Beschorner arrived at the facility on June 10, 2021 at 10:20 AM to conduct an Annual/Required Visit. Upon LPA arrival, LPA's temperature was checked at the front desk and LPA signed a COVID questionnaire. LPA met with Executive Director Marguerite Crockem. Crockem accompanied LPA on a tour of the inside and outside of the facility and the following was observed:

All staff are wearing a surgical mask while working at the facility. LPA observed the dining area to have 2 chairs at each table. Each meal is served in phases. The first phase is served at a specific time on one side of the dining room and the second phase is served on the opposite side of the dining room at a different time. This allows each side to be disinfected after each use. Residents can choose to eat in their room and a tray of food will be taken to their room.

LPA observed the outside entertainment area to have table and chairs with umbrellas for protection of the residents. All entertainment is being provided outside at this time. Chairs are brought out and placed six feet from each other. All residents wear face masks during entertainment and a piece of plexi glass is placed between the residents and the entertainer.
Crockem stated she oversees the infection control procedures and trains all staff and residents on COVID prevention. LPA observed the facility has at least a 30-day supply of PPE and all infection control procedures are being followed.

An exit interview was conducted and a copy of this report was provided to Executive Director Marguerite Crockem. No citations or technical violations are being issued at this time.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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