Facility Evaluation Report

Licensing Program Analysts (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Gantesetseg Tsedendamba and discussed the purpose of today’s visit. LPA also spoke to Erdenetuya Ulziibaatar via telephone and discussed the purpose of this visit.

This is a single story home with (4) resident rooms, (1) bathroom for residents and (1) bathroom for staff, living room, dinning room and kitchen.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for (6) non-ambulatory residents, of which, (1) may be bedridden (bedroom #1) and (3) may be on hospice. There are currently (2) residents under hospice care.

Physical Plant & Environment Safety: LPA toured facility grounds. Smoke alarms and carbon monoxide detectors were observed (both tested and operable). Fire extinguishers are located in the hallway and kitchen. The wall connected signal system was tested and operable. The water temperature measured as follows: 106* in the hallway bathroom and 114* in the bathroom near the kitchen. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars.

Refer to LIC 809C for the continuation of this report.