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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603725
Report Date: 04/11/2023
Date Signed: 05/02/2023 04:47:36 PM


Document Has Been Signed on 05/02/2023 04:47 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, 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: 35DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Edgardo GalangTIME COMPLETED:
01:15 PM
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On 04/11/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Edgardo Galang and the purpose of today’s visit was explained. The facility is licensed to serve seventy (70) non- ambulatory residents ages 60 and above and have an approved hospice waiver for a maximum of 3 hospice residents.

The facility is a large four-story building located in a residential neighborhood. The facility consists of resident rooms, common area, dining area, kitchen, an outdoor shaded area, a laundry room, a gym, 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 conducted a records review of (5) resident records, all resident records were complete. (3) staff records, (5) Medication Administration Records and did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual up to date. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The last fire drill was conducted on 03/27/2023. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, (3) fire extinguishers were fully charged and are located and mounted in each floor, and 1 fire extinguisher located in the kitchen.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed, walls and floors were clean and in good repair, bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F..

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ST. RICHARD PAMPURI
FACILITY NUMBER: 197603725
VISIT DATE: 04/11/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were locked and inaccessible to residents. A landline was observed, each resident has a working phone in their room. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit LPA to discrepancies were observed.

Exit interview conducted with administrator Edgardo Galang and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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