366426055-11-19-2021-18-AS-NBRN-CCLQNQ-20220317121931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:00:30 PM

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
09/22/2021 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 18-AS-20210922080754

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: 79	DATE:	11/19/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Marguerite Crockem		TIME COMPLETED:	02:07 PM

ALLEGATION(S):

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Staff did not respond to resident's calls for help.
Facility has not reimbursed resident for cost of lost property.
Staff are not meeting resident's showering needs.
Staff are not meeting resident's personal hygiene needs.
Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted a complaint visit to deliver findings on the above allegations. LPAs met with Marguerite Crockem, Executive Director, and explained the nature of today’s visit. LPA Bueno conducted the investigation and interviewed staff and resident and reviewed facility files.

Allegation #1: Staff did not respond to resident's call for help. Records reveal that care services continued regardless of whether the call button was operational. This allegation is unsubstantiated.
Allegation #2: Facility has not reimbursed resident for cost of lost property. Reporting Party (RP) informed LPA Bueno that resident received a reimbursement check for the lost property. This allegation is unsubstantiated.
***CONTINUED ON LIC 9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

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-20210922080754

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: 11/19/2021

NARRATIVE

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Allegation #3: Staff are not meeting resident's showering needs. Interviews with RP and staff reveal that Resident 1 (R1) refuses showers and prefers bed baths. This allegation is unsubstantiated.
Allegation #4: Staff are not meeting resident's personal hygiene needs. Interviews with staff and RP reveal that R1 would refuse services. This allegation is unsubstantiated.
Allegation #5: Staff handled resident in a rough manner. Interviews with RP and staff reveal that R1 was not handled in a rough manner. LPA Bueno was not able to find enough evidence that the incident did or did not occur. This allegation is unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and a copy was provided to the Executive Director.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
09/22/2021 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210922080754

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: 79	DATE:	11/19/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Marguerite Crockem		TIME COMPLETED:	02:07 PM

ALLEGATION(S):

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Resident's call button is broken.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted a complaint visit to deliver findings on the above allegation. LPA met with Marguerite Crockem, Executive Director, and explained the nature of today’s visit. LPA Bueno conducted the investigation and interviewed staff and resident and reviewed facility files.

Call light log records reviewed show that the resident's call button was not operable between 9/18/2021 at 12:34 AM through 9/20/2021 1:00 PM. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20210922080754

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: 11/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/19/2021 Section Cited CCR 87303(i)(1)(B)	1 2 3 4 5 6 7	(i)(1)(B): Facilities shall have signal systems...All facilities licensed for 16 or more..Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall ensure R1's call button is operating or an alternative call system is available. The licensee has an operable call button for R1 as of 9/20/2021 1:01 PM.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not ensure that R1's call system was operable.	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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4