366426055-11-30-2023-18-AS-RSTS-CYWSAA-20231227124158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:15:16 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200428122059

FACILITY NAME:	BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)		FACILITY NUMBER:	366426055
ADMINISTRATOR:	MARGUERITE CROCKEM		FACILITY TYPE:	740
ADDRESS:	28807 BASELINE STREET		TELEPHONE:	(909) 742-7353
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY:	115	CENSUS: 90	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Marguerite Crockem, Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident was found injured outside the facility requiring hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Executive Director, Marguerite Crockem, and informed her of the purpose for her visit.

The Department investigation consisted of interviews, a review of resident records, and medical records. It was alleged staff neglect led to Resident One (R1) being injured and requiring hospitalization.

Interview revealed, R1 was found on 04/24/2020, outdoors, on the facility premises. 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. It was reported R1 was outside, sitting in a chair, directly in the sun, and unresponsive. R1 was observed with blisters on the leg, arms, hands, and elbows. It was reported when staff removed R1’s clothing, R1’s blisters popped.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200428122059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/30/2023

NARRATIVE

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During the course of the investigation, Staff One (S1) could not be interviewed. Staff interviews revealed, the facility has a policy to observe and document resident’s whereabouts every 30 minutes. Staff are required to submit a Thirty Minute Log which includes the room number of every resident they are assigned to. The staff are required to document where in the facility the resident is located on this log, when they make their observation. S1 was assigned to supervise R1 on 04/24/2020. A review of the Thirty Minute Log, which included R1’s room number, dated 04/24/2020, revealed, R1 was seen in the TV room, every 30 minutes, starting at 12:30pm until 2:30pm. One staff interview revealed, S1 made a statement that they had last seen R1 at 1:45pm when they provided a service to R1.

Staff interviews contradicted the Thirty Minute Log filed by S1. S1 was last observed at 1pm, when they left the unit they were assigned, to participate in a staff celebration and was not seen returning to the unit until 2pm. Staff interviews did not reveal the last time R1 was observed. Staff interview revealed that R1 had not been seen during lunch, which is between 11am and 11:30am. The investigation shows R1 was outside for an unspecified amount of time. Discharge Summary from the hospital, dated 04/28/2020, revealed R1 was diagnosed with Second Degree Sunburn.

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 immediate civil penalty of $500 is being assessed during today’s visit. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted where this report, LIC9099D, LIC 811, LIC421IM, and appeal rights were discussed and provided to the Executive Director.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20200428122059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General Facility personnel shall at all times be … and competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Based on interviews and records the Licensee did not ensure facility personnel was competent to	1 2 3 4 5 6 7	The ED stated staff were in-serviced on 30-minute status checks, in addition to the installation of water misters & shading in outdoor areas used by residents. LPA received proof of the in-service training & observed the shading that was incorporated in the facility courtyard. POC is cleared.
	8 9 10 11 12 13 14	provide the services necessary to meet R1's needs. S1 did not demonstrate competency when they did not follow facility policy of observing R1 every 30 minutes, resulting in R1 sustaining 2nd degree burns. This posed an immediate threat to the health and safety of the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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