Routine inspection·February 6, 2024

On 2/6/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by staff, Uranchimeg Turmurbaatar. Administrator, Chuluunchimeg Young was contacted and arrived later in the visit. The facility is licensed for 5 non-ambulatory and 1 bedridden resident with a hospice capacity of 2. The facility currently provides care for 3 residents, none of which are receiving hospice services and none of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility to be recently purchased on 1/9/2024 at the time of visit. Smoke and carbon monoxide detectors are interconnected throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate labeling. Staff provide residents with meals according to dietary restrictions with an ample amount of fresh and healthy foods observed. Cleaning supplies and other toxins are safely stored in a locked closet in the hallway, under kitchen sink and garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured under the kitchen sink. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water was measured at faucets accessible to residents and measured between 109.6 and 112.2 degrees F which is within regulation. Continued onto LIC809-C Medications located in designated cabinet in the kitchen area and were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Residents that were awake during the inspection were observed interacting with staff in the common area or in their bedroom reading for leisure. The facility also offers regular family visits and gatherings as well as encouraging residents to exercise and increase their mobility. There are two emergency exits located in the backyard which were found to be unobstructed. There is an indoor patio and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. All auditory alarms leading out of the facility including resident bedroom emergency exits were also tested and all found to be in working order. The facility conducts emergency disaster drills but LPA advised Administrator to continue documentation indicating quarterly dates moving forward. Technical Advisory issued. Residents utilizing hospital bed or bed rails were found to have appropriate medical orders on file. In addition, signage for use of oxygen were posted at each door of residents requiring the use. Staff quarters were located towards the facility entrance and is kept inaccessible to residents. LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found that all resident Needs & Service Plans and Physician's Reports to be current. All required positing and signeage at the front of the facility were found to be in order with information easily accessible for staff and residents. Administrators Chuluunchimeg Young's Administrator Certification 6 046470740 and Administrator Alex Young's Administrator Certification 6046477740 are currently pending for renewal. LPA confirmed receipt of documentation and certification payments submitted to the department. LPA requested the following documents be sent to CCL by COB 2/20/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance Control of Property/Rental Agreement No deficiencies cited