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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426055
Report Date: 01/23/2023
Date Signed: 01/23/2023 09:38:25 AM


Document Has Been Signed on 01/23/2023 09:38 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:
01/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Amber Nelson, Resident Care ManagerTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit to this facility regarding an report received by the Department on 1/20/2023. LPA met with memory care resident manager (RM) Amber Nelson. The following is a summary of the incident:

On 1/20/2023, LPA received communication from the facility regarding the placement of Resident 1 (R1). LPA was also informed that R1 was yelled at by staff in the facility.

During today's visit, LPA discovered that R1 was not yelled at by staff on 1/20/23. LPA discovered that R1 was in an outing when they had an incident. Records reviewed show that the facility has been trying to get in touch with R1's responsible party to seek a more appropriate setting for R1.

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: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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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