Brightwater Senior Living Of Highland (dba)

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Licensee does not ensure sufficient staffing to meet residents’ care needs. Regarding the allegation LPA reviewed facilities staff directory and observed that the facility has sufficient staff that will meet resident care needs daily. LPA conducted interviews with R#1, R#2, R#3, R#4, and R#5, regarding the alleged allegation and five out of five residents informed LPA that facility has enough care support to meet their care needs. In addition, five out of five residents informed LPA that facility provides good laundry services as well as housekeeping services. R#1-5 informed LPA that they feel safe and caregivers respond to their call services right away. R#1-5 denied witnessing staff nRead the full finding— CDSS inspection report, November 25, 2025 · control 56-AS-20241107140947

Licensing Program Analysts (LPA) Becky Mann and Edith Conchas conducted an unannounced visit to the facility to initiate a complaint investigation. LPAs met with Marguerite Crockem, Administrator and explained the purpose of today's visit. The investigation consisted of LPAs observations, pertinent document reviews, and interviews with staff and residents. The allegation that resident was left unattended in urine and feces for extended periods, resulting in bedsores. Five (5) staff interviewed denied leaving resident(s) unattended in urine and feces for extended periods, resulting in bedsores. Four (4) of five (5) residents interviewed stated that staff has not left them unattended in urine and feces for extended periods. Based on LPAs observations while interviewing the resident's in their rooms, LPAs did not observe resident's in soiled clothing and linens. There was no unpleasant odor observed by LPAs. UnsubstantiatedRead the full finding— CDSS inspection report, May 12, 2025 · control 56-AS-20240315160632

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. SubstantiatedRead the full finding— CDSS inspection report, November 30, 2023 · control 18-AS-20200428122059

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegation. LPA met with Resident Care Coordinator Ruth Villa, LVN and disclosed the elements of the complaint investigation. Investigation consisted of interview with Ruth Villa and review of the records for one (1) resident (R1). It is alleged that R1 was given the wrong dose of a narcotic pain medication. Interview with Resident Care Coordinator revealed that the allegation is accurate. R1 had a routine order for 5 mg of the medication Norco. On 09/11/2023 a nurse dropped off medication intended for R1 as post-operative pain management for after a scheduled upcoming surgery. The medication received by the facility was for 10 mg of the medication Norco, and did not have a physicians order or direction provided. The facility mistakenly thought that the medication was a refill of the 5 mg routine order of the medication Norco. The facilRead the full finding— CDSS inspection report, October 4, 2023 · control 56-AS-20230926135046

Licensing Program Analyst (LPA) Javina George made and unannounced visit to deliver findings for the allegation noted above. LPA met with Execuitve Director Marguerite Crockem and explained the purpose of the visit and the elements of the allegation. The department investigated the allegation, the investigation consisted of observations, interviews and records review. Resident #1 (R1) was admitted to the facility on 05/02/2014 without any noted pressure injuries or wounds. On 01/02/2020, Staff #1 (S1) reported to the Residential Care Manager (S2) that R1 had a wound located on their left heel and described it as "an about a 3-inch by 3-inch circle with blackness inside the circle and redness around it". After seeing the wound, S2 did nothing and waited until the following day. At that time is when S2 assessed the area, then notified R1’s responsible party, and spoke with them about R1 receiving hospice services. However, there was no additional follow up with R1’s Primary Care PhysiciaRead the full finding— CDSS inspection report, September 12, 2023 · control 18-AS-20200226162945

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings on the above complaint allegation. LPA met with Mrs. Crockem. The investigation included interviews with resident and staff and records review. It is alleged that Staff did not apply ointment as prescribed. LPA reviewed records and found that Resident 1 (R1) was first seen on 12/26/22 for a rash an nonspecific skin eruptions. Witness and staff interviews confirmed that R1 continued to have skin issues throughout and was last seen on 07/15/23 and treated for scabies. LPA reviewed medication records and found scabies medication Permethrin cream was administered on 07/28/23 through 07/30/23 and 08/3/23 through 08/5/23. While staff interviewed stated that the cream is administered one time every two weeks, recorded administration of the cream does not follow the two week schedule. Furthermore, LPA interviewed R1 who is able to verbalize their needsRead the full finding— CDSS inspection report, August 14, 2023 · control 56-AS-20230807153844

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the complaint allegations above and deliver findings. LPA and met with Amber Nelson, Memory Care Director (MCD), who was informed of the reason for today’s visit and the elements of the allegation. Executive director (ED) Marguerite Crockem arrived shortly and was informed of the purpose the visit however ED left the memory care unit before the conclusion of the investigation. The investigation included LPA observations, staff and residents interviews, and records review. Allegation 1: R1 sustained unexplained injury while in care. Interviews with staff deny that bruising was observed on R1's hands nor has their spouse who visits daily has spoken to staff about the bruising. Staff interviews also reveal that R1 is under hospice care and is visited by a shower nurse and a registered nurse regularly. LPA reviewed records showing that hospice visited R1 on 5/8/23, 5/9/34, 5/11/23, 5/15Read the full finding— CDSS inspection report, May 26, 2023 · control 56-AS-20230523152910

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 occRead the full finding— CDSS inspection report, October 19, 2022 · control 56-AS-20221013102111

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the above mentioned complaint allegation and deliver findings. LPA identified herself to Health Services Coordinator Angie Lafler 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 staff interviews and records review. It is alleged that the Facility mismanaged resident's medications. On 9/15/22, Resident 1 (R1) ran out of one (RX) of their two scheduled medication. Records reveiwed showed that the facility continued to update the medication record for RX as DNA-Drug not available on 9/16/22 and 9/17/22 and as HLD-Medication on Hold from 9/18/22 through the morning of 10/6/22. The RX was filled in the evening of 10/6/22 and R1 has been taking the RX consistently to date. Records reviewed and staff interviews revealed thatRead the full finding— CDSS inspection report, October 12, 2022 · control 56-AS-20221006095346

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to commence a complaint investigation and deliver findings on the above allegation. LPA identified herself to executive director Marguerite Crockem, who was notified of the reason for today’s visit. Allegation 1: The allegation is that staff served resident (R1) an eviction letter containing incorrect information. On 8/1/2022, this facility sent a copy of R1's eviction letter copy to the Department with the Long-Term Care Ombudsman's phone number as (909)891-3928 and the Department's number as (951)248-2222. Allegation 2: Staff did not provide resident with reappraisal. Records review show that R1 physian's report was completed on 8/30/21, a facility history and physical report was updated on 4/30/22, and the quarterly service plan was completed on 7/12/22. Based on the available information, we have found the complaint allegation is UNFOUNDED. **************continued on LIC 9099-C************** URead the full finding— CDSS inspection report, August 25, 2022 · control 56-AS-20220817151703