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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:11:29 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221013102111
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: 91DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Marguerite CrockemTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervison to resident resulting in resident sustaining injuries while in care.
Staff did not ensure that resident's toileting needs were met while in care.
Staff did not administer resident's medication(s) as prescribed.
Staff did not seek medical attention for resident in a timely manner.
Staff did not adhere to resident's care plan.
Staff do not have the adequate skills to transport resident(s) in a safe manner.
Staff did not properly manage resident's incontinence care resulting in infection.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the complaint allegations above and deliver findings. LPA identified herself to business office manager Danielle who was notified of the reason for today’s visit and the elements of the allegation. Executive director Marguerite Crockem arrived shortly and was informed of the purpose of today's visit. The investigation included LPA observations, staff and residents interviews, and records review. Resident 1 (R1) did not want to speak with LPA.

Allegation 1: Staff did not provide adequate supervision to R1 resulting in R1 sustaining injuries while in care. Records reviewed show that R1 was discovered by staff to have a laceration on their leg and was sent to the hospital. Interviews with staff and third parties revealed that R1 was by themselves in their room when they were found with laceration. Third party interviewed disclosed that R1 was on their mobile chair when the incident occurred however there were no actual witnesses to the incident but that it occurred inside R1’s room. This allegation is unsubstantiated.
Allegation 2: Staff did not ensure that R1's toileting needs were met while in care. LPA observed two staff
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221013102111

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: 91DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Marguerite CrockemTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not properly manage resident's medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the complaint allegations above and deliver findings. LPA identified herself to business office manager Danielle who was notified of the reason for today’s visit and the elements of the allegation. Executive director Marguerite Crockem arrived shortly and was informed of the purpose of today's visit. The investigation included LPA observations, staff and resident interviews, and records review.

It is alleged that staff did not properly manage resident's medications. During the investigation, LPA reviewed medication and medication administration record (MAR) and found that medications matched. Staff interviews reveal that when the resident is out of the facility, it is recorded on the MAR and when resident return, staff resume medication from the last day that was dispensed.

A finding of 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. An exit interview was conducted with Mrs. Crokem and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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 5
Control Number 56-AS-20221013102111
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
, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2022
Section Cited
CCR
87465(h)(5)
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(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee shall conduct a random medication audit for 10 percent of the current population. Proof shall be submitted to the Department no later than the end of the POC date.
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This requirement is not met as evidenced by:
Staff interviews that one scheduled medication is pre-poured. LPA observed pills for days 20 and 21 were not inside the medicine bubble pack.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20221013102111
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
, CA 92507
FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
VISIT DATE: 10/19/2022
NARRATIVE
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change resident’s soiled brief and clothes immediately after a third-party visit. Interviews with witnesses reveal that R1 is clean and dry when seen by witnesses. Resident interviews reveal that they call staff when they need toileting assistance. This allegation is unsubstantiated.
Allegation 3: Staff did not administer resident's medication(s) as prescribed. Records reviewed and LPA observations revealed that medication record and medication match on dates when R1 was not in the facility. Staff and witness interviews reveal that medication is administered accordingly, sometimes with apple sauce but whole and uncrushed to aid R1 swallow the medication. Resident interviews reveal that they call staff when they are receiving their medication timely. This allegation is unsubstantiated.
Allegation 4: Staff did not seek medical attention for resident in a timely manner. LPA observed staff using mobile devices and walkie talkies at work. LPA observed communication devices in use and observed nurses respond to staff request for assistance. Interviews with staff reveal that residents are sent to the hospital after nurse assessment. Resident interviews that they can contact staff when they need immediate medical assistance by pushing their pendant. This allegation is unsubstantiated.
Allegation 5: Staff did not adhere to resident's care plan. Records reviewed show that R1’s care plan was updated less than 45 days ago. Interviews with staff and third party confirm that R1 hired a personal caregiver not associated to this facility less than 45 days ago. LPA observed several staff assist R1 multiple times during today’s visit. This allegation is unsubstantiated.
Allegation 6: Staff do not have the adequate skills to transport resident(s) in a safe manner. LPA observed 2 staff transfer R1 manually. Witness interview shared that they observed staff to safely transfer residents. Resident interviews reveal that they feel comfortable with staff transferring them to and from their beds and chairs. This allegation is unsubstantiated.
Allegation 7: Staff did not properly manage resident's incontinence care resulting in infection. LPA observed 2 staff change resident’s soiled brief and clothes immediately following a third-party visit. LPA could not find corroborating paperwork indicating that R1 developed an infection from lack of incontinence care. Resident interviews reveal that their briefs are regularly changed by staff and residents can get in touch with staff by way of their pendant necklace. This allegation is unsubstantiated.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20221013102111
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
, CA 92507
FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)
FACILITY NUMBER: 366426055
VISIT DATE: 10/19/2022
NARRATIVE
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A finding of 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. An exit interview was conducted with Mrs. Crokem and a copy of this report was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5