197603725-4-29-2024-11-AS-EGOZ-D4STKK-20240429144805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603725
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:48:23 PM

Document Has Been Signed on 04/29/2024 02:48 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ST. RICHARD PAMPURI		FACILITY NUMBER:	197603725
ADMINISTRATOR:	EDGARDO B. GALANG		FACILITY TYPE:	740
ADDRESS:	2458 S. ST. ANDREWS PLACE		TELEPHONE:	(323) 731-0641
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	70	CENSUS: 58	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Arjene Aguirre		TIME COMPLETED:	03:00 PM

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

On 4/29/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual inspection visit to the above facility using the CARE tool. LPA was met by Arjene Aguirre, Assistant Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve seventy (70) non-ambulatory residents aged 60 and above. Hospice waiver approved for a maximum of 3 hospice residents. Currently there are fifty-eight (58) residents in care.

The facility is a large four-story building located in a residential neighborhood. The facility consists of 60 resident rooms and each containing a bathroom, community restrooms, dining area, an outdoor shaded area, a laundry room, a gym, media room, a beauty salon, a swimming pool which the activity coordinator is a certified in water safety and drowning hazards, reception area, medication room and administrative offices.

LPA Gonzalez and Arjene Aguirre toured the physical plant inside and out. There were no bodies of water or obstructions on the premises. Resident rooms were inspected. Bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Bathrooms were clean and operational and found to be within Title 22 regulations. Toilets and water faucets worked properly, shower was free of mold/mildew, and there was adequate lighting, and sufficient toiletries accessible to residents. During the inspection, LPA observed the water temperature measured above 120.0 F in all rooms inspected. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. A comfortable temperature was maintained in the facility.

Sufficient perishable and non-perishable food supply was maintained adequately in the facility. Sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to clients. A landline was observed, each resident has a working phone in their room.

Continued on LIC809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST. RICHARD PAMPURI	FACILITY NUMBER: 197603725
	VISIT DATE: 04/29/2024

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
26
27
28
29
30
31
32

Exits/ Walkways around the facility were free of debris and hazards. Medications were centrally stored and properly locked. Smoke detectors and carbon monoxide were tested and are working properly. Fire extinguishers were fully charged. A stocked First Aid kit along with manual was available.

Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

During this inspection, deficiencies were cited, please refer to LIC 809-D.

An exit interview was conducted, and a copy of report and Appeal Rights was provided to Assistant Administrator, Arjene Aguirre.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/29/2024 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST. RICHARD PAMPURI	FACILITY NUMBER: 197603725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having hot water measure more than 120 F. degrees, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Licensee will ensure faucets used by residents will deliver water less than 120 F. degrees. As a plan of correction, licensee will create a log measuring the hot water every 2 hours. Licensee will submit this log to LPA as POC via email to Elvira.Gonzalez@dss.ca.gov before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3