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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502984
Report Date: 04/14/2023
Date Signed: 04/14/2023 02:16:11 PM

Document Has Been Signed on 04/14/2023 02:16 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SOUTHSIDE MANORFACILITY NUMBER:
191502984
ADMINISTRATOR:JAMES (GARY) PARDUEFACILITY TYPE:
735
ADDRESS:820 EAST GRAND AVENUETELEPHONE:
(909) 623-7305
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 38CENSUS: 26DATE:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Danielle Loboda and Craig PardueTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Danielle Loboda/S-1. LPA explained the purpose of today's visit. Craig Pardue (Facility Administrator) arrived at approximately at 9 A.M..

Facility is a single story home located in a residential area. The property has 7 buildings. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. This facility is approved for (38) ambulatory clients.

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 sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: The fire clearance is approved for (38) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 02/20/23. Staff are adhering to operational requirements.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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: SOUTHSIDE MANOR
FACILITY NUMBER: 191502984
VISIT DATE: 04/14/2023
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Craig Pardue expires on 05/14/24 and HIV Training Certificate is dated 11/10/21. Administrator Certificate for Danielle Loboda expires on 07/13/24 and HIV Training Certificate is dated 11/10/21. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and S-1 through S-4. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files. Per Co-Administrator, some clients have their own phone with internet services and some clients do not know how to use the internet.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-5. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Client Cash Resources
Staffing: There is sufficient staffing at the facility. Administrator Certificate for Craig Pardue expires on 05/14/24 and
HIV Training Certificate is dated 11/10/21. Administrator Certificate for Danielle Loboda expires on 07/13/24 and HIV Training Certificate is dated 11/10/21. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and S-1 through S-4. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files. Per Co-Administrator, some clients have their own phone with internet services and some clients do not know how to use the internet.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-5. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Incidental Medical Services: Per Co-Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Emergency Intervention : Not-Applicable.

Due to time constraints, LPA will return to this facility to complete the annual inspection. The following domains remain pending: Physical Plant and Environment Safety, Food Service, Health Related Services and Disaster Preparedness.

No deficiencies noted during this visit.

Exit interview, appeals rights and a copy of this report was provided to Danielle Loboda., Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Incidental Medical Services: Per Co-Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Emergency Intervention : Not-Applicable.

Due to time constraints, LPA will return to this facility to complete the annual inspection. The following domains remain pending: Physical Plant and Environment Safety, Food Service, Health Related Services and Disaster Preparedness.

No deficiencies noted during this visit.

Exit interview, appeals rights and a copy of this report was provided to Danielle Loboda.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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