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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426055
Report Date: 02/21/2023
Date Signed: 02/21/2023 09:52:09 AM


Document Has Been Signed on 02/21/2023 09:52 AM - It Cannot Be Edited

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
, 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: 88DATE:
02/21/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:MARGUERITE CROCKEMTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Bernadette Allen and Magda Malcore conducted an unannounced visit to the facility to interview resident 1 (R1) regarding complaint investigation 56-AS-20221102154307. LPA's met with Marguerite Crockem who was informed of the purpose of the visit.

During the visit Marguerite Crockem informed LPA's that the resident was moved to another facility because of needing a higher level of care and during the visit details of the residents needs were discussed. The LPA's were given the name and number of the new facility where the resident was moved.

An exit interview was discussed and a copy this report was provided to Marguerite at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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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