Sunray Assisted Living

Type of visit: Required - 1 Year

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. Facility Tour & Observations 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. Physical Plant 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. (Continued on LIC809C) Smoke/carbon monoxide detectors were functional, fire extinguisher was available in kitchen and by resident bedrooms, and no bodies of water were present. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed. Food Service Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer. Health-Related Services & Records Five (5) residents files were reviewed and contained current required documents Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status and Rights acknowledgments. During record review it was found that currently a resident is residing in the facility with a g-tube. The resident is not under hospice care. Five (5) residents’ medications were reviewed; medications were observed to be centrally stored in a locked kitchen cabinet. MAR logs were observed to be current Disaster Preparedness Last fire/earthquake drill was conducted on Sember 30, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted on kitchen bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated. Personnel Records & Training Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for was valid through June 6, 2026. Insurance Liability insurance was in compliance with an expiration date of September 1, 2026. An exit interview was conducted with Erdenetuya Ulziibaatar Toga, Administrator During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. The Administrator was advised of the nature of the deficiency, the regulatory basis, and the required Plan of Correction (POC). The Administrator agreed to submit proof of correction by the due dates specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Erdenetuya Ulziibaatar . LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 09/23/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Erdenetuya Ulziibaatar is pending renewal. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. 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 six (6) non-ambulatory of which one (1) may be bedridden. This facility may retain no more than three (3) hospice residents. There were two (2) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed Resident files for three (3) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. During resident records reviewed, R2 and R3 did not have a written statement signed by thier roommate (or responsible party) acknowledging and giving voluntary access to the shared living space to hospice caregivers and a residents network of family, friends and clergy. Last medical assessment and reappraisal for R2 was conducted May of 2023. One (1) violation was observed during visit. Exit interview conducted. A copy of this report, 809-D, and appeals rights was provided.the state’s words, verbatim · CDSS document, Nov 12, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.