LLC Retirement Homes II

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit on June 5, 2026 to conduct a Case Management visit. LPA met with Licensee Lindsey Lamerson over the phone and explained the purpose of today's visit. LPA returned file/ records for former facility Resident 1. No deficiencies cited or observed during visit. Exit interview conducted with Licensee, Lindsey Lamerson, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jun 5, 2026

Allegation investigated: Resident sustained bruises and fractures due to physical abuse Staff do not report injuries to resident's responsible party Staff do not provide responsible party with resident's records Staff do not ensure that resident is hydrated Staff are not distributing resident's medications as prescribed Staff are not adhering to resident's dietary plan Staff do not communicate with responsible party regarding resident's care Staff did not assist resident with obtaining care Staff did not provide a safe environment for resident in care

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with Licensee, Lindsey Lamerson and explained the purpose of today's visit. Regarding the allegation that resident sustained bruises and fractures due to physical abuse, interviews and records reviewed did not reveal evidence that facility staff physically abused the resident. Medical records documented the resident had multiple chronic medical conditions, mobility impairment, chronic knee and hip pain, edema, fall risk, use of blood thinners, and a history of bruising easily. Records further documented prior falls, fractures, weakness, and the resident’s need for assistance with ambulation and transfers. Home health documentation reflected bruising concerns were evaluated and monitored, including recommendations to pad bedrails and wheelchair components to reduce accidental bruising. During interviews, the reporting party acknowledged they never witnessed staff physically abuse the resident and stated they were unsure whether bruising was intentional or related to incompetence or accidental causes. Ombudsman documentation reviewed by LPA reflected no concerns of abuse at the facility and noted the bruising was believed related to blood thinner use and the resident’s medical condition. The Investigations Bureau reviewed the complaint and declined further investigation after determining records and statements obtained did not show evidence of physical abuse. Based on interviews and records reviewed, the allegation is deemed Unsubstantiated. Unsubstantiated Regarding the allegation that staff did not report injuries to the resident’s responsible party, records and interviews indicated the responsible party was notified regarding falls, medical concerns, appointments, bruising observations, and hospitalization's. The reporting party acknowledged receiving calls, texts, photographs, and updates from facility staff regarding incidents and changes in the resident’s condition. Although the reporting party expressed dissatisfaction regarding the timeliness or adequacy of certain communications, evidence obtained did not demonstrate staff failed to notify the responsible party of injuries or medical concerns. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff did not provide the responsible party with resident records, LPA reviewed the written request for records submitted by the reporting party through legal counsel. The request sought extensive facility and medical documentation and additionally requested information regarding the cost associated with reproduction of records. Facility records reviewed by LPA included copies of the requested records assembled by facility staff, mailing documentation, certified mail receipts, and postage records demonstrating the records were mailed to the reporting party. Although the licensee generated an invoice reflecting copying and preparation costs, interviews confirmed no payment was requested prior to release and the records were nevertheless provided. Based on documentation reviewed, the allegation is deemed Unsubstantiated. Regarding the allegation that staff did not ensure the resident was hydrated, LPA reviewed medical records, resident interviews, and observations made during facility visits. Medical records documented the resident received ongoing medical monitoring, physician follow-up appointments, home health services, and hospital care when needed. Resident interviews conducted by LPA revealed residents stated staff routinely provide beverages, meals, and assistance as needed. During facility visits, LPA observed beverages and water accessible to residents throughout the facility. No evidence was obtained showing facility staff intentionally withheld fluids or failed to provide hydration. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff were not distributing medications as prescribed, LPA reviewed available records and conducted interviews. Records reviewed reflected the resident routinely attended medical appointments and received ongoing physician oversight. No evidence was obtained establishing staff intentionally withheld medications or failed to administer medications as ordered. Interviews conducted during the investigation further indicated residents receive medications routinely and timely. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff were not adhering to the resident’s dietary plan, records reviewed reflected the resident was recommended a low sodium diet; however, records and interviews further demonstrated the resident remained under ongoing physician monitoring and continued attending routine medical appointments throughout residency. Interviews indicated the resident was verbal and capable of expressing food preferences and participating in decisions regarding activities and meals. Facility staff did offer salads, healthy choices, and rarely used salt in day to day cooking. No evidence was obtained demonstrating the resident suffered injury or harm due to meals provided by the facility. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff did not communicate with the responsible party regarding the resident’s care, interviews indicated the concern partially related to the resident attending a Mother’s Day brunch outing without prior notification to the responsible party. Interviews and records reviewed reflected the resident was verbal, capable of expressing preferences, and elected to attend the outing. Evidence obtained during the investigation demonstrated ongoing communication occurred between facility staff and the responsible party through calls, text messages, photographs, appointment coordination, and medical discussions. While disagreements existed regarding decision-making and care preferences, evidence did not support that facility staff failed to communicate regarding the resident’s care. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff did not assist the resident with obtaining care, records reviewed demonstrated the resident routinely attended physician appointments, hospital visits, home health services, hospice services, therapy services, and follow-up care throughout residency. Interviews further indicated facility staff assisted with transportation coordination, medical follow-up, and implementation of physician recommendations. Therefore, the allegation is deemed Unsubstantiated. Regarding the allegation that staff did not provide a safe environment for residents in care, LPA conducted resident interviews and facility observations. Residents interviewed stated they felt safe residing at the facility and denied witnessing abuse or mistreatment. Residents further stated staff responded when assistance was needed and treated them appropriately. LPA observed residents to appear appropriately dressed, clean, and comfortable within the facility environment. Although records documented the resident experienced falls and bruising, evidence obtained did not establish the facility intentionally created or maintained an unsafe environment. Therefore, the allegation is deemed Unsubstantiated. Exit interview conducted with Licensee, Lindsey Lamerson and copy of report provided.the state’s words, verbatim · CDSS document, May 9, 2026 · control 24-AS-20260116102232

Allegation investigated: Staff mismanaged residents medication records

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations lsited above. LPA met with Licensee, Lindsey Lamerson and explained the purpose of today's visit. Regarding the allegation that staff mismanaged resident’s medication records, Licensing Program Analyst (LPA) Sarah Hurt conducted interviews and reviewed facility records including physician orders, over the counter PRN medication administration records, medication logs, and additional documentation maintained by facility staff regarding physician notification for over the counter PRN medication administration. LPA reviewed multiple over the counter PRN medication administration records maintained by the facility for the resident. Records reviewed documented over the counter PRN medications administered for symptoms including pain, anxiety, and other symptoms. LPA reviewed handwritten documentation maintained by the facility reflecting staff communication with the house manager and/or physician regarding over the counter PRN medication administration. Documentation reviewed reflected the facility maintained an internal process in which staff notified the house manager and/or physician when over the counter PRN medications were needed for the resident.. LPA identified documentation deficiencies within the PRN medication records. LPA observed several entries on the over the counter PRN medication administration records which contained incomplete documentation including missing times, incomplete results documentation, missing follow-up entries regarding effectiveness of medication administration, and inconsistent documentation regarding symptom resolution following administration of over the counter PRN medications. LPA did not observe evidence indicating the resident suffered harm related to the medication administration practices reviewed. However, the facility failed to ensure over the counter PRN medication records were consistently and accurately completed as required. . Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficincies are being cited Per title 22 regulations. Exit interview conducted with Licensee, Lindsey Lamerson and copy of report provided along with appeals rights provided. Substantiatedthe state’s words, verbatim · CDSS document, May 9, 2026 · control 24-AS-20260501091427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: May 23, 2026

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. The following requirement has not been met as evidenced by: Resident 1's PRN tracking log was not accurate and did not include all times PRN given, and results, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2026

Plan of correction: Licensee agrees to complete the following: Review and audit all resident PRN medication records to ensure documentation includes:date and time administered,medication administered, reason for administration,staff initials/signature,resident response/results following administration, and follow-up documentation when required, and submit proof to LPA by POC date of 05/23/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Lindsey Lamerson, Continual Administrator's Certification expires 02/05/2027. There are currently 6 residents who reside at this home and there is 1 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. Required hospice training is not inside Resident 1's hospice binder. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Licensee, Lindsey Lamerson, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility Licensee Lindsay Lamerson, Continual Administrator's Certification for Licensee Lindsay Lamerson expires 02/05/2025. There are currently 6 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed 3 facility staff files, and 3 facility resident files. LPA reviewed your Infection Control Plan, and Emergency Disaster Plan. Resident 1 is missing Pre Admission assessment. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with facility Licensee Lindsay Lamerson, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Lindsey Lamerson, Continual Administrator's for Administrator, Lindsey Lamerson 02/05/2025. There are currently 5 residents who reside at this home and there is 3 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 111 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt confirmed all staff present is background cleared. The facility has an updated Emergency Disaster Plan. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Lindsey Lamerson and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jan 22, 2024