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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002922
Report Date: 03/05/2026
Date Signed: 03/05/2026 01:07:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2025 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20251009114942
FACILITY NAME:BRILLIANT CARE HOMEFACILITY NUMBER:
315002922
ADMINISTRATOR:NESBITT, KARLAFACILITY TYPE:
740
ADDRESS:1105 NOB HILL COURTTELEPHONE:
(916) 993-3133
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
03/05/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Karla Nesbitt, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Questionable death.
Staff did not properly supervise residents who are a fall risk.
Staff did not provide resident with activities.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20251009114942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BRILLIANT CARE HOME
FACILITY NUMBER: 315002922
VISIT DATE: 03/05/2026
NARRATIVE
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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.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2