AURORA, Colo. -- State and local law enforcement had an opportunity to quickly conduct a criminal investigation of a woman found performing unlicensed plastic surgeries in Aurora, but they didn't because of a breakdown in communication, Contact7 Investigates has learned.
It is illegal to tell someone that you're a doctor when you're not licensed to be a doctor in Colorado. Yet, despite those well-established principles and laws, a foreign national from Mongolia was accepting plastic surgery patients in the back of a beauty salon for at least a month.
State regulators received an anonymous complaint from a man in early May who said, "Starting from mid of Apr. this year 2018, there has been facial plastic surgery being operated inside of [She-A Beauty Salon] which I believe, by unlicensed foreigner."
Three days later, investigators from the Department of Regulatory Agencies (DORA) responded to the salon and confirmed with the salon owner that a woman named Altannamar Tserendorj was performing plastic surgeries in a back room after hours.
The salon owner had sutures in her face when investigators arrived, DORA records say. She explained "that in exchange for allowing Altannamar to use the salon to perform the surgeries, Altannamar performed a surgery on [her] eye lids for free."
Contact7 Investigates obtained the full case file, which includes photos of syringes, foreign medication and blood stains, through a Colorado Open Records Act request.
Roughly three weeks after investigators visited the salon, state regulators issued a cease and desist order -- a civil action -- against Tserendorj telling her to stop performing medical jobs without a state license.
The markedly faster response came just weeks after Contact7 Investigates first exposed a breakdown at DORA that allowed numerous unlicensed health care workers -- including an unlicensed psychologist, doctor and dentist -- to ignore cease and desist orders and thrive.
However, despite the well-documented investigation conducted by DORA on the unlicensed plastic surgeon, the case never reached the district attorney's office for possible prosecution. The case file indicates DORA investigators made direct attempts to get Aurora police involved, but police never formally pursued the matter and there's no record of DORA following up.
District Attorney George Brauchler and his staff weren't aware of the case until Contact7 Investigates called them around the beginning of this month.
"Well, I think you could have a renewed focus," he said when asked if state regulators should have more power, and stiffer penalties, to pursue unlicensed health care workers.
"This was a system that was created by people, and anything created by people is not going to be perfect and it's going to have flaws," Brauchler said. "Frankly, investigative stories like this one, many times, help us to discover areas where we have fallen short or there may be a leak that we're not even aware of."
Commanders at the Aurora Police Department declined multiple requests from Contact7 Investigates to speak on-camera, but issued a statement saying, in part, "The Aurora Police Department continues to work diligently with its law enforcement partners to establish clear procedures on how we received and investigate these types of cases."
APD acknowledges that "as crime and technology evolves, so must our practices and procedures." It also encourages the community to contact them directly if anyone suspects criminal activity involving a medical facility.
Nonetheless, the She-A Beauty Salon is now closed. The now-former salon owner did not want to speak with Contact7 when reached at her home in Aurora.
Contact7 attempted to reach Tserendorj over the phone, online, and in-person to no avail. Her phone number no longer works and she has not responded to messages on social media.
Another woman, Shuree Chilkhaa, who was implicated in working with Tserendorj at times, has also not responded to Contact7 and no longer lives at her most recent address.
Given their now-unknown whereabouts, it's unclear if either of them -- especially Tserendorj -- will ever face criminal charges.
A handful of critics of Contact7's reporting on unlicensed health care workers have said on social media that health care licenses are not entirely necessary. But Brauchler balks at those assertions saying there's "not a chance" that he would ever recommend getting rid of the licensing.
"It probably goes back to snake oil salesmen, which, it's not just fraud, some of this stuff is risky," he said.
Brauchler did suggest, however, that licensing of hair stylists is not entirely necessary.
"Look, at the end of the day the worst haircut on the planet Earth goes away in about 3 to 4 weeks, right? Some of the stuff that these quacks are doing won't ever go away, and won't ever be fixed, and can lead to worse health outcomes. That does need to be regulated."