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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426055
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:41:22 AM


Document Has Been Signed on 01/13/2023 11:41 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: 95DATE:
01/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Amber NelsonTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility to discuss an incident report that was received by the Department on 12/13/22. LPAs met with memory care resident manager (RM) Amber Nelson. The following is a summary of the incident:

On 12/8/22, Staff 1 (S1) was heard by RM and Staff 2 (S2) yelling at Resident 1 (R1). RM went out of their office and observed S1 holding the arm of R1 and yelling and cursing at them. RM and S2 separated S1 and R1. RM and S2 brought R1 inside RM's office. S1 stated that they were leaving work and was allowed to collect their personal items. On their way out of the facility, S1 went inside RM's office and said that they would hurt R1.

Records reviewed during today's visit show that S1 did not return to work since 12/8/22 and was separated from this facility as of 12/14/22. No deficiencies were cited during today's visit. An exit interview was conducted where a copy of this report was provided to Ms. Nelson.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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