Inspection Report Summary
Most inspections at Brightwater Senior Living of Highland were clean, with the most recent report from May 12, 2025, finding no deficiencies after a complaint investigation. Earlier reports included several substantiated complaints related mainly to resident care issues such as medication errors, neglect resulting in injuries like pressure wounds and sunburn, and failure to follow timely medical protocols. The facility received civil penalties totaling at least $1,000 for these incidents, including a $500 fine for neglect leading to injury and another $500 for delayed medical attention. Many complaint investigations were unsubstantiated, indicating that some concerns were not supported by evidence. The trend shows improvement over time, with recent annual inspections in 2024 and 2025 reporting no deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 87
Capacity: 115
Deficiencies: 0
May 12, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-03-15 regarding resident neglect and staff conduct at Brightwater Senior Living of Highland.
Findings
The investigation found the allegations unsubstantiated after interviews with staff and residents, observations, and document reviews. No evidence was found to support claims of residents being left unattended in soiled conditions, rough handling by staff, or untimely assistance.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 115
Census: 87
Staff interview count: 5
Resident interview count: 5
Staff assistance time: 7
Staff assistance time: 10
Resident assistance time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Mann | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Edith Conchas | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Marguerite Crockem | Administrator | Facility administrator met during the investigation |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 85
Capacity: 115
Deficiencies: 0
Mar 18, 2025
Visit Reason
An unannounced visit was conducted for the required annual inspection of the facility.
Findings
The facility was found to be operating within capacity and in good condition, with no deficiencies cited. The physical plant, kitchen and food service, medication management, resident and staff files, and operations and administration were all compliant with regulatory requirements.
Report Facts
Hospice Waiver Capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marguerite Crockem | Executive Director | Met with Licensing Program Analyst during inspection and mentioned in operations and administration |
| Renese Howell-Small | Licensing Program Analyst | Conducted the inspection visit |
| Enrique Serralta | Maintenance Manager | Assisted in touring the exterior of the facility |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 92
Capacity: 115
Deficiencies: 0
Feb 6, 2024
Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced visit to this facility for a required annual inspection.
Findings
The facility was found to be operating within capacity and in good condition, clean, sanitary, and free of foul odors. No deficiencies were cited during this visit. Medications were dispensed according to physician's orders, and staff and resident files contained required documentation.
Report Facts
Hospice Waiver Capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marguerite Crockem | Executive Director | Met with Licensing Program Analyst during inspection and named in operations and administration section. |
| Anna Bueno | Licensing Program Analyst | Conducted the inspection and medication review. |
| Enrique Serralta | Maintenance Manager | Toured the interior of the facility with Licensing Program Analyst. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 115
Deficiencies: 1
Nov 30, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 04/28/2020 regarding a resident found injured outside the facility requiring hospitalization.
Findings
The investigation substantiated that staff neglect led to Resident One (R1) sustaining second degree sunburn due to failure to follow the facility's 30-minute observation policy. Staff One (S1) did not demonstrate competency, resulting in R1 being outside unsupervised and injured.
Complaint Details
The complaint was substantiated. Resident One was found outside the facility with blisters and unresponsive, requiring hospitalization. Staff failed to observe the resident as required, leading to injury. An immediate civil penalty of $500 was assessed, with additional penalties under review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel did not demonstrate competency by failing to follow the policy of observing Resident One every 30 minutes, resulting in second degree burns to the resident. | Type A |
Report Facts
Civil penalty: 500
Capacity: 115
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Marguerite Crockem | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 115
Deficiencies: 1
Nov 30, 2023
Visit Reason
The visit was an unannounced case management inspection to address a violation observed during the investigation of complaint #18-AS-20200428122059 involving a resident found outdoors with injuries and delayed medical attention.
Findings
The investigation found that staff failed to immediately contact 9-1-1 when a resident was found with second degree sunburn and signs of heat stroke, instead contacting hospice and applying cooling measures, which posed an immediate threat to the resident's health. A citation was issued for failure to seek timely medical attention.
Complaint Details
The visit was triggered by complaint #18-AS-20200428122059 regarding a resident found outdoors with injuries and unresponsive condition. The complaint was substantiated based on interviews and records.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not immediately contact 9-1-1 when a resident had an apparent life-threatening medical crisis, instead contacting hospice and beginning cooling measures, posing an immediate threat to resident health. | Type A |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Dec 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marguerite Crockem | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Stephanie Martinez | Licensing Program Analyst | Conducted the unannounced visit and authored the report |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 1
Oct 4, 2023
Visit Reason
This unannounced visit was conducted to investigate a complaint alleging that staff mishandled a resident's medication while in care.
Findings
The investigation substantiated the complaint that a resident was given the wrong dose of the medication Norco (10 mg instead of the ordered 5 mg) without a physician's order from 09/11/2023 through 09/19/2023. The facility implemented a plan of correction including medication cart audits and staff training.
Complaint Details
Complaint was substantiated. The allegation that staff mishandled a resident's medication by administering an incorrect dose without a physician's order was found valid.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Assistance with self-administered medications was not limited to those authorized by the person's physician, as evidenced by providing a resident with the wrong dose of Norco from 09/11/2023 through 09/19/2023. | Type A |
Report Facts
Capacity: 115
Census: 91
Deficiencies cited: 1
Plan of Correction Due Date: Oct 5, 2023
Medication error duration days: 9
Medication technician/nurse training date: Sep 25, 2023
Medication cart audits frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ruth Villa | Resident Care Manager | Interviewed during investigation and involved in findings |
| Nedra Brown | Licensing Program Manager | Oversaw licensing program and signed report |
| Marguerite Crockem | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 1
Sep 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect by staff resulting in a resident sustaining a pressure injury while in care.
Findings
The investigation found sufficient evidence to substantiate neglect by facility staff in providing proper care and supervision to Resident #1, who developed a pressure injury that was not treated timely or properly. Nine care staff received written warnings for not being aware of the wound, and an immediate civil penalty of $500 was assessed.
Complaint Details
The complaint was substantiated. The allegation was neglect by staff resulting in a resident sustaining a pressure injury. The investigation included observations, interviews, and records review, confirming neglect and failure to follow medical orders.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The Licensee failed to ensure that Resident #1 received treatment for the wound in a timely manner, posing a potential health, safety, and personal rights risk to persons in care. | Type B |
Report Facts
Civil penalty: 500
Written warnings: 9
Deficiency due date: Sep 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marguerite Crockem | Executive Director | Facility representative met during investigation and exit interview |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 115
Deficiencies: 1
Aug 14, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/07/2023 alleging that staff did not apply ointment as prescribed, did not bathe a resident, and did not keep a resident's room clean.
Findings
The investigation substantiated the allegation that staff did not apply ointment as prescribed, posing a potential health and safety risk. The allegations that staff did not bathe the resident and did not keep the resident's room clean were unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding failure to apply ointment as prescribed. The allegations that staff did not bathe the resident and did not keep the resident's room clean were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer prescribed ointment and allergy medication as ordered, with medication administration records not matching medical orders. | Type B |
Report Facts
Capacity: 115
Medication administration date: 1
Plan of Correction due date: Aug 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marguerite Crockem | Executive Director | Facility representative met during investigation and exit interview |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 115
Deficiencies: 0
May 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including unexplained injury to a resident, residents being left in soiled diapers, neglect, and failure to provide clean linens.
Findings
All allegations were found to be unsubstantiated after observations, interviews with staff and residents, and records review. Residents were observed to be clean and well cared for, and no evidence supported the complaints.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unexplained injury, residents left in soiled diapers, neglect, and failure to provide clean linens. Interviews and observations did not support these allegations.
Report Facts
Capacity: 115
Census: 95
Dates of hospice visits: 5
Laundry service frequency: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation |
| Marguerite Crockem | Administrator / Executive Director | Facility administrator present during investigation |
| Amber Nelson | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 115
Deficiencies: 0
Feb 21, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding resident 1 (R1) related to complaint investigation number 56-AS-20221102154307.
Findings
The Licensing Program Analysts interviewed the resident and met with the facility administrator who informed them that the resident was moved to another facility due to needing a higher level of care. Details of the resident's needs were discussed and the new facility information was provided.
Complaint Details
Complaint investigation 56-AS-20221102154307 was conducted. The resident was no longer at the facility as they had been moved to another facility requiring a higher level of care.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marguerite Crockem | Administrator | Met with Licensing Program Analysts during complaint investigation and provided information about resident transfer. |
| Bernadette Allen | Licensing Program Analyst | Conducted unannounced visit and complaint investigation. |
| Magda Malcore | Licensing Program Analyst | Conducted unannounced visit and complaint investigation. |
| Karen Clemons | Licensing Program Manager | Named in report header. |
Inspection Report
Census: 95
Capacity: 115
Deficiencies: 0
Jan 23, 2023
Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced case management visit regarding a report received by the Department on 2023-01-20 about the placement of Resident 1 and an allegation that Resident 1 was yelled at by staff.
Findings
The visit found that Resident 1 was not yelled at by staff on 2023-01-20; Resident 1 was on an outing when an incident occurred. The facility has been trying to contact Resident 1's responsible party to seek a more appropriate setting. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Nelson | Resident Care Manager | Met with Licensing Program Analyst during visit and was provided a copy of the report. |
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Marguerite Crockem | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 115
Deficiencies: 0
Jan 13, 2023
Visit Reason
The visit was an unannounced case management incident investigation conducted to discuss an incident report received by the Department on 12/13/22 involving staff behavior towards a resident on 12/8/22.
Findings
The investigation found that Staff 1 was observed yelling and holding a resident's arm aggressively, and subsequently threatened the resident. Staff 1 was separated from the facility as of 12/14/22. No deficiencies were cited during the visit.
Complaint Details
The complaint involved Staff 1 yelling at and holding the arm of Resident 1, followed by a threat to hurt the resident. Staff 1 was separated from the facility and did not return to work after 12/8/22. No deficiencies were cited.
Report Facts
Capacity: 115
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Nelson | Memory Care Resident Manager | Met with during the visit and involved in the incident report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 1
Oct 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations regarding inadequate supervision, toileting care, medication administration, timely medical attention, adherence to care plan, safe resident transport, and incontinence care at Brightwater Senior Living of Highland.
Findings
All allegations were found to be unsubstantiated after observations, staff and resident interviews, and records review. However, a Type B deficiency was cited for improper medication storage, specifically that one scheduled medication was pre-poured and pills for certain days were not inside the medicine bubble pack.
Complaint Details
The complaint included allegations of inadequate supervision resulting in injury, unmet toileting needs, improper medication administration, delayed medical attention, non-adherence to care plan, unsafe resident transport, and improper incontinence care resulting in infection. All allegations were investigated and found unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not stored in their originally received containers; one scheduled medication was pre-poured and pills for days 20 and 21 were not inside the medicine bubble pack. | Type B |
Report Facts
Facility capacity: 115
Census: 91
Deficiencies cited: 1
Plan of Correction due date: Oct 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marguerite Crockem | Administrator | Facility administrator present during investigation and exit interview |
Inspection Report
Census: 92
Capacity: 115
Deficiencies: 0
Oct 19, 2022
Visit Reason
An unannounced visit was conducted to deliver an amended report related to complaint control number 56-AS-20221013102111.
Findings
The findings for the complaint control number remain unsubstantiated. No deficiencies were cited during the visit.
Complaint Details
Complaint control number 56-AS-20221013102111 was investigated and found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced visit and delivered the amended report. |
| Marguerite Crockem | Administrator | Facility administrator present during the visit and received the report. |
| Nedra Brown | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 115
Deficiencies: 1
Oct 12, 2022
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that the facility mismanaged a resident's medications.
Findings
The complaint was substantiated as the facility failed to communicate with Resident 1's responsible party that a scheduled medication ran out and was not filled for an extended period, posing an immediate health and safety risk to residents.
Complaint Details
The complaint was substantiated. The facility mismanaged Resident 1's medications by failing to notify the responsible party that the medication ran out on 9/15/22 and was not filled until 10/6/22. This posed an immediate health and safety risk to residents in care.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not communicate with Resident 1's family that the medication had not been filled until 10/5/22 after it ran out on 9/15/22, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 115
Census: 90
Deficiency due date: Oct 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marguerite Crockem | Administrator | Facility administrator informed of the complaint and investigation |
| Angela Lafler | Health Services Coordinator / Director | Met with Licensing Program Analyst during the investigation and discussed findings |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 115
Deficiencies: 0
Aug 25, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 08/17/2022 regarding eviction letter errors, failure to provide resident reappraisal, and staff interference with resident obtaining medical care.
Findings
The investigation found all allegations to be unsubstantiated or unfounded, meaning there was insufficient evidence to prove violations occurred. The eviction letter contained correct information, reappraisal was provided, and staff did not interfere with resident medical care.
Complaint Details
The complaint investigation addressed three allegations: 1) staff served a resident an eviction letter containing incorrect information, 2) staff did not provide resident with reappraisal, and 3) staff interfered with resident obtaining medical care. All allegations were found to be unsubstantiated or unfounded.
Report Facts
Facility capacity: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Marguerite Crockem | Executive Director | Facility representative met during investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 81
Capacity: 115
Deficiencies: 0
Mar 25, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain.
Findings
No health and safety concerns were observed at the time of the visit, and no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. The facility demonstrated compliance with infection control measures including COVID-19 mitigation plans, symptom screening, PPE supply, and fire safety maintenance.
Report Facts
Capacity: 115
Census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Ridenour | Acting Executive Director | Met with Licensing Program Analysts during inspection |
| Angie Lafler | Health Services Director | Met with Licensing Program Analysts during inspection |
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the inspection |
| Anna Bueno | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 115
Deficiencies: 1
Nov 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 09/22/2021 regarding staff response to resident calls for help, reimbursement for lost property, resident showering and hygiene needs, and rough handling of a resident.
Findings
The investigation found one allegation substantiated: the resident's call button was broken and not operable between 9/18/2021 and 9/20/2021. All other allegations regarding staff response, reimbursement, showering, personal hygiene, and rough handling were unsubstantiated. A deficiency was cited for failure to ensure an operable call system.
Complaint Details
The complaint investigation was triggered by allegations including staff not responding to resident calls, failure to reimburse for lost property, unmet showering and hygiene needs, and rough handling of a resident. The call button being broken was substantiated; other allegations were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that Resident 1's call button was operable, violating CCR 87303(i)(1)(B) requiring signal systems for facilities licensed for 16 or more residents. | Type B |
Report Facts
Capacity: 115
Census: 79
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bernadette Allen | Licensing Program Analyst | Assisted in conducting the complaint visit |
| Marguerite Crockem | Executive Director | Facility administrator met during investigation |
| Nedra Brown | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 67
Capacity: 115
Deficiencies: 0
Jun 10, 2021
Visit Reason
The inspection visit was an Annual/Required Visit conducted to evaluate the facility's compliance with regulations, including infection control procedures during the COVID-19 pandemic.
Findings
The facility was found to be in compliance with infection control procedures, including proper use of PPE, social distancing during meals and entertainment, and adequate training on COVID prevention. No citations or technical violations were issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marguerite Crockem | Executive Director | Met with Licensing Program Analyst and oversaw infection control procedures. |
| Pauline Beschorner | Licensing Program Analyst | Conducted the annual inspection visit. |
| Karen Clemons | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 115
Deficiencies: 2
May 13, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 12/22/2020 regarding medication administration, cleanliness, communication, food service, injuries, verbal abuse, and admission agreement issues at Brightwater Senior Living of Highland.
Findings
The investigation substantiated two allegations: failure to administer resident's medication per physician orders and failure to maintain the resident's bedroom clean. Several other allegations including failure to promptly respond to calls, failure to inform representatives of health changes, inadequate food service, verbal abuse, injuries caused by staff, and failure to provide admission agreement copy were found unsubstantiated or unfounded.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff did not administer resident's medication per physician orders and did not clean the resident's bedroom. Other allegations including failure to respond to calls, failure to inform representatives of health changes, inadequate food service, verbal abuse, injuries caused by staff, and failure to provide admission agreement copy were unsubstantiated or unfounded.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not competent to provide necessary services, evidenced by failure to administer prescribed medication to Resident One (R1). | Type A |
| Facility did not maintain R1's bedroom clean at all times, including an overflowing cat litter box and dusty conditions. | Type B |
Report Facts
Medication administration re-education sessions: 5
Resident weight gain: 3
Medication doses missed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced complaint investigation visit and authored the report. |
| Marguerite Crockem | Executive Director | Facility representative interviewed during the investigation and named in relation to findings. |
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