Facility Evaluation Report

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Administrator Erdenetuya Ulziibaatar Toga explained the reason for the visit.

The facility is licensed for six (6) non-ambulatory of which one (1) may be bedridden. This facility may retain no more than three (3) hospice residents.

No residents were on hospice care during visit.

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

The facility is in a residential area and is a one-story home consisting of four (4) resident bedrooms with one being vacant, two (2) bathrooms, living room, kitchen, dining area, attached garage, front yard, and backyard. Each resident bedroom contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). Cleaning supplies and toxic substances are inaccessible to residents locked in kitchen cabinet. LPA observed a Hoyer lift in vacant room and living room per administrator used only when needed. Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 114.3°F and bathroom (2) 105.9°F which is within the required 105–120°F. Extra linens and towels were available in the hallway closet.