Facility Evaluation Report

On 01/21/2029 at approximately 1:45PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Administrator, Chuluunchimeg Young. Facility has an approved fire clearance and capacity for 1 ambulatory, 4 non-ambulatory, and 1 bedridden resident and has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 2 residents in care and 1 staff member on-site. Facility is a 1 story building with 4 Resident bedrooms, 3 bathrooms, and common spaces.

At approximately 2:05PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 02:15PM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. LPA recommended to keep toxins separate from kitchen utensils. Toxins are stored in a locked kitchen cabinets under the sink and cabinets in the laundry room. Water temperature measured 109.6 degrees F and 107.4 which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were bought new on 01/04/2025 and has not been inspected since. Gauge was on green zone (Technical advice given). Carbon Monoxide detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.