247209026-5-15-2026-24-AS-SMOA-DU8LL5-20260519085035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247209026
Report Date: 05/09/2026
Date Signed: 05/15/2026 08:17:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2026 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20260116102232

FACILITY NAME:	LLC RETIREMENT HOMES II		FACILITY NUMBER:	247209026
ADMINISTRATOR:	BRYANT, PAULA		FACILITY TYPE:	740
ADDRESS:	1944 FAXON DR		TELEPHONE:	(209) 761-2478
CITY:	ATWATER	STATE: CA	ZIP CODE:	95301
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee, Lindsey Lamerson		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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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

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2026

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 3

Control Number 24-AS-20260116102232

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LLC RETIREMENT HOMES II	FACILITY NUMBER: 247209026
	VISIT DATE: 05/09/2026

NARRATIVE

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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.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20260116102232

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LLC RETIREMENT HOMES II	FACILITY NUMBER: 247209026
	VISIT DATE: 05/09/2026

NARRATIVE

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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.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2026

LIC9099 (FAS) - (06/04)

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