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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603574
Report Date: 11/12/2024
Date Signed: 11/12/2024 03:27:47 PM

Document Has Been Signed on 11/12/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNRAY ASSISTED LIVINGFACILITY NUMBER:
198603574
ADMINISTRATOR/
DIRECTOR:		ULZIIBAATAR, ERDENETUYAFACILITY TYPE:
740
ADDRESS:3205 N. TOWNE AVETELEPHONE:
(213) 254-7022
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 3DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Erdenetuya UlziibaatarTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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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
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNRAY ASSISTED LIVING
FACILITY NUMBER: 198603574
VISIT DATE: 11/12/2024
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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.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 03:27 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 11/12/2024 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRAY ASSISTED LIVING
FACILITY NUMBER: 198603574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R2 did not have annual medical assessment and reappraisal the licensee did not comply with the section cited above in 1 out of 3 residnets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee will send proof of medical assessment and reappraisal for R2 by 11/26/24, via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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