Brilliant Care Home

Allegation investigated: Questionable death. Staff did not properly supervise residents who are a fall risk. Staff did not provide resident with activities.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Administrator Karla Nesbitt during today’s inspection. LPA investigated allegation, “Questionable death”. The department interviewed relevant parties and staff, and reviewed hospital and facility documentation and obtained the death certificate. On 9/7/25 R1 had a fall at the facility and was admitted into the ER with a chief complaint of a fall and hip fracture. R1 and relevant parties were advised by hospital doctor about the risks of a surgery for R1. On 9/9/25 R1’s surgery took place and during the surgery R1 lost their pulse and deceased. R1’s death certificate states that the immediate cause of death was coronary artery disease, end stage renal disease, hypertension, myotonic dystrophy type 2, and aortic stenosis status post, transcatheter aortic valve replacement, and hypothyroidism. Continuation on 9099-C. Unsubstantiated A review of medical records and death certificate indicates that the hip fracture was not the immediate cause of R1’s death. Furthermore, it is unclear if the hip fracture was due to staff neglect. The evidence does not support the allegation; therefore, the allegation is Unsubstantiated. LPA investigated allegation, “Staff did not properly supervise residents who are a fall risk.” The department interviewed relevant parties and staff, and reviewed hospital and facility documentation. On 9/7/25 R1 was admitted to the hospital with a chief complaint of a fall and hip fracture. Prior to this fall, R1 sustained approximately four falls while in care which resulted in injuries such as head injury, black eye, ear laceration, and an injury to their arm. Administrator and staff were interviewed in which they stated they were doing all they could to prevent R1’s falls. R1 had access to a call button, half bed rails, and a bed sensor to prevent falls. Staff were also checking on R1 every 30 minutes or less. Although R1 sustained several falls, there is not enough evidence to support that staff did not properly supervise resident; therefore, the allegation is Unsubstantiated. LPA investigated allegation, “Staff did not provide resident with activities”. LPA interviewed staff and residents and toured the facility. Relevant party stated facility staff had an activity calendar posted however they never engaged R1 in any activities. LPA interviewed 3 staff in which they stated R1 enjoyed a variety of activities from puzzles, playing cards, walking and gardening. Administrator stated that R1 had a garden bed that they would garden in frequently. Administrator stated that not many residents want to participate in group activities, so they engage the residents with more of 1-on-1 activities. LPA toured the facility and observed different activities available for resident use. LPA interviewed a resident in which they stated they are not interested in activities provided. Due to the information gathered LPA finds allegation to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 59-AS-20251009114942

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Karla Nesbitt, and explained the purpose of the visit. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to resident bedrooms, bathrooms, kitchen, common areas and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 114.3 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher is located in the kitchen and was last serviced on 06/18/2025. LPA observed required Licensing posters posted in the entry of the facility. LPA observed medications to be locked and inaccessible to residents in care. LPA reviewed five (5) resident files. Resident files contained all required documentation. LPA reviewed three (3) staff records. Staff have all required documentation and first aid training. No deficiencies are being cited during today's inspection. Exit interview conducted and a copy of the report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Facility did not provide adequate supervision to resident resutling in resident sustaining severe injuries resulting in death.

On 01/29/25, Regional Manager Alycia Rayner, Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to deliver complaint findings and met with Administrator, Karla Nesbitt. The department conducted records review ,facility observations, staff and residents interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099..... Allegation- Facility did not provide adequate supervision to resident resulting in resident sustaining severe injuries resulting in death. On August 28, 2024, at approximately 7:45 am, staff witnessed R1 in R2’s room standing over R2 while R2 was in bed. Interviews described witnessing R2 “covered in blood” and R1’s hands “covered in blood.” Staff quickly separated the two residents and 911 was called. R2 was taken to the hospital and diagnosed with significant facial trauma and swelling, tenderness and swelling to left eye, nasal bridge, and bilateral maxilla. Bleeding profusely from the left Nare and upper lip laceration approximately 0.5 cm. Medical records notated R2 passed away while at the hospital on September 3, 2024. The cause of death was listed as “Blunt Head Trauma.” Based on interviews conducted and documents reviewed, R1 had behaviors of wandering and going into other residents’ rooms during the day and night, however, interviews and documentation did not indicate R1 exhibited aggressive behaviors towards other residents. On August 28, 2024, it was reported that staff checked on R1 around 6:30 am. It was noted that R1 was awake but in their room. Staff then went on to finish their rounds, assisting other residents, and started cooking breakfast. Per facility policy and needs and service plans, both R1 and R2 were to be checked on every two hours by staff. Interviews reported that based on R1’s behaviors of wandering, staff were instructed to follow them and re-direct to the common areas. R1 at times showed aggression or agitation towards staff when they were showering or re-directing R1, but that aggression never resulted in physical violence. Based on interviews conducted and documents reviewed, the incident on August 28, 2024, wherein R2 was assaulted by R1 was an isolated incident. Although R2 sustained severe injuries while in care, neither R1 nor R2 required 1:1 care and supervision. Staff could not have predicted R1’s aggressive behavior would result on the assault of R2 therefore the allegation is UNSUBSTANTIATED. A finding that a complaint allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 59-AS-20240830164210

Type of visit: Required - 1 Year

Licensing Program Manager (LPM)- Laura Munoz, Regional Manager - Alycia Rayner ,Licensing Program Analyst (LPA) -Talwinder Bains arrived on 01/29/25 to conduct the annual inspection. CCL staff met with Administrator, Karla Nesbitt and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. Staff reviewed medications of four (4) residents comparing with physician orders . Staff reviewed four (4) residents files and two (2) staff files and found all required paperwork. Staff and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 112 degrees F, which is within the regulation range of 105-120 degree. Fire extinguisher was last serviced on 06/21/24 and was ready for emergency use. Citations were observed and issued as listed on LIC809-D per Title 22 ,CCR Regulations from this visit. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 02/10/25. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. Staff did not dispense medication as prescribed and did not properly store resident's medications. Resident did not have access to call button. Staff did not provide adequate supervision to resident in care.

On 08/01//24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings and met with staff, Daniel Smith who contacted Administrator, Karla Nesbitt. Administrator was not available to come and gave permission to staff, Daniel Smith to sign the report. The department conducted records review ,facility observations, staff and residents interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated ***Report continued from 9099...... Allegation- Staff left residents in soiled diapers for an extended period of time.-UNSUBSTANIATED The Department conducted facility’s observations, record review and interviewed three (3) residents and three (3) staff members to investigate the complaint allegation. During staff interviews it was learned that the facility has a 2-hour check rotation. 3 of 3 staff stated they were checking on R1 at hourly at which time they would check on resident, rotate resident and provided incontinence care when needed. Administrator stated R1 was checked on regularly. Based on gathered information, It was determined that staff were checking R1 at least every two hours, usually more often, therefore the allegation is UNSUBSTANTIATED. Allegation- Staff did not dispense medication as prescribed and did not properly store resident's medications. -UNSUBSTANIATED The Department conducted facility’s observations, record review and interviewed three (3) residents and three (3) staff members to investigate the complaint allegation. Records were reviewed for resident’s medications for July 2024. Records reflected that facility was managing resident’s medications per their physician’s orders with proper record keeping per Department’s Regulations. 3 staff interviews conducted on 07/08/24 indicated that staff were giving resident’s medications per their physician’s orders and there were no problems to address. 3 residents interviews conducted on 07/24/24 reflected no medications mismanagement issues by facility staff. Based on this information, this allegation was found to be UNSUBSTANTIATED. ***Report continued to 9099-C..... ***Report continued from 9099-C..... Allegation- Resident did not have access to call button. .-UNSUBSTANIATED The Department conducted facility’s observations, record review and interviewed three (3) residents and three (3) staff members to investigate the complaint allegation. 3 staff interviews conducted on 07/08/24 indicated that staff provide access to call buttons for all residents and assist them when called, however there were some residents who were not able to use call button due to their health issues, so staff check on them regularly to address their care needs. 3 residents interviews conducted on 07/24/24 reflected that they have access to their call button and staff assist them in timely way and there were no problems. During Department visits on 07/08/24 and 07/24/24, it was observed that residents have access to their call button, and they were using them as needed. Based on this information, this allegation was found to be UNSUBSTANTIATED. Allegation- Staff did not provide adequate supervision to resident in care. .-UNSUBSTANIATED The Department conducted facility’s observations, record review and interviewed three (3) residents and three (3) staff members to investigate the complaint allegation. 3 staff interviews conducted on 07/08/24 indicated that staff provide care and supervision to all residents per their needs and service plan and there were no problems. Administrator stated that they conduct training with their staff to go over any residents’ care issues concerns and address them in timely way. 3 residents interviews conducted on 07/24/24 reflected that their care needs were met at facility and staff assist them in timely way and there were no problems. During Department visits on 07/08/24 and 07/24/24, it was observed that staff were attentive to residents’ care needs and residents were observed to be in good care. Based on this information, this allegation was found to be UNSUBSTANTIATED. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above all allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of this report was provided to the facility. The signature of the staff on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 59-AS-20240703132523

Type of visit: Required - 1 Year

On 02/09/2024 at 12:58 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Karla Nesbitt, and explained the purpose of the visit. At 1:10 PM, LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 110 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 05/10/2023. Fire drill was last conducted on 02/5/2024. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility. At 1:30 PM, LPA reviewed a total of two (2) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Feb 9, 2024