198603574-11-3-2023-28-AS-EIRA-CX8PKB-20231103112254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603574
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:22:57 AM

Document Has Been Signed on 11/03/2023 11:22 AM - 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 LIVING		FACILITY NUMBER:	198603574
ADMINISTRATOR:	ULZIIBAATAR, ERDENETUYA		FACILITY TYPE:	740
ADDRESS:	3205 N. TOWNE AVE		TELEPHONE:	(213) 254-7022
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 3	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Gantsetseg Tsedendamba		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: 11/03/2023

NARRATIVE

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Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #3 (R-3). 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, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. The facility has (2) refrigerators inside the kitchen. Posted menu observed in the kitchen. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating.

Health Related Services/Incidental Medical Services: The medications are stored inside a locked file cabinet located in the living room.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.

Staffing Domain: Pending.
Personnel Records-Training: Pending.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Olga Zamora

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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