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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426055
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:11:52 AM


Document Has Been Signed on 11/30/2023 11:11 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
Lookup Error,
, CA



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: 90DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Marguerite Crockem, Executive DirectorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to address a violation observed during the investigation of complaint #18-AS-20200428122059. The LPA met with Executive Director, Marguerite Crockem, and informed her of the purpose for her visit.

The investigation revealed R1 was found on 04/24/2020, outdoors, on the facility premises, with observable injuries. The exact time of when R1 was found could not be determined. It was reported R1 was found sometime between 2:15pm and 2:50pm. Interviews reported R1 was outside, sitting in a chair, directly in the sun, and unresponsive. Interviews revealed R1 was observed with blisters on the leg, arms, hands, and elbows.

Staff One (S1) reported R1's condition did not rise to a level of an emergency and the hospice agency was contacted instead, per facility protocol. Interviews revealed S2 told the caregivers to take R1 to the shower to cool the resident down. R1's hospice nurse documented receiving a call from the facility at 3:30 pm reporting that R1 seemed to have had a “heat stroke” and cooling measures were being done. The Nurse arrived at the facility at 4:20 pm and found R1 in bed unresponsive, with cooling measures being done. According to the Nurse, R1 still felt hot to the touch and their temperature was at 103.5 ⁰F. The Nurse stated that 911 was called during their visit. It was reported that when paramedics arrived, R1 started to seize as they were being transported to the hospital. A Discharge Summary from the hospital, dated 04/28/2020, revealed R1 was diagnosed with Second Degree Sunburn.

Therefore, based on interviews and records, a citation will be issued due to failure to seek timely medical attention. An exit interview was conducted where this report, LIC 809D and appeal rights were discussed and provided to the Executive Director.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 11:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87465(g)

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Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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The ED stated a policy was already in place regarding contacting emergency medical services when an incident occurred not involving a resident's hospice diagnosis. The ED stated an in-service was conducted regarding the policy and provided the LPA with a copy of the training. POC is cleared.
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This requirement was not met, as evidenced by: Based on interviews and records, facility staff did not immediately contact 9-1-1, rather staff contacted R1's hospice and began cooling measures for the resident. This posed an immediate threat to the health and safety of the resident in care.
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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: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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