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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603725
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:48:36 PM


Document Has Been Signed on 04/05/2022 05:48 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ST. RICHARD PAMPURIFACILITY NUMBER:
197603725
ADMINISTRATOR:SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2458 S. ST. ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:70CENSUS: 24DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Edgardo GalangTIME COMPLETED:
03:45 PM
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On 4/5/2022, Licensing Program Analysts (LPAs) Ngozi Nwaokoro conducted an unannounced visit for the annual inspection, with emphasis on Infection Control. LPAs met with Administrator, Edgardo Galang, and explained the purpose of today's visit. The facility is licensed to serve 70 non-ambulatory residents, age 60 and above, and a maximum of 3 hospice residents. LPA Nwaokoro and Administrator toured the facility, review resident records, medication and MARs and staff record.

LPA Nwaokoro and Administrator toured the entire facility. The First floor includes the Lobby, dining room, kitchen, indoor pool, fitness room, 2 community restrooms, library, 3 administrative offices, Wellness office, alert panel room, medication room/clinic, art room, gift shop, beauty salon, staff lounge and a janitor room. The second floor has resident bedrooms (each containing a bathroom), 1 community restroom, Media room, meditation room and an emergency food storage room. Third floor has resident bedrooms (each containing a bathroom), Games room, 1 community restroom and a laundry room. The fourth floor also has resident bedrooms (each containing a bathroom), locked file room, activities room, a community restroom, and a storage room.

Residents rooms are on the second, third and fourth floors. All the rooms are self-contained. Bedrooms contained the required linen and furniture. Bathrooms are clean and operational, smoke detectors/carbon monoxide detectors are working and operable. Fire extinguishers are fully charged. The last fire drill was on 3/28/2022. The first aid kit with manual was observed to be in compliance. The hot water temperature measured at 118.2-degree F.

Continue on LIC 809C
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ST. RICHARD PAMPURI
FACILITY NUMBER: 197603725
VISIT DATE: 04/05/2022
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All indoor and outdoor passageways are kept free of obstruction. The indoor swimming pool is locked and inaccessible to residents. The facility maintains a comfortable temperature for residents and has sufficient lightings in the hallways. LPA observed the nonperishable and perishable supply of food to be in compliance.
Medications are centrally stored and locked in the Clinic room. All resident files have Medical Assessments, Appraisals and Needs service plan documented as necessary, and individual written admission agreements.

No deficiencies cited in today’s visit. An exit Interview conducted, and a copy of the report was given to the Administrator, Edgardo Galang.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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