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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502984
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:30:10 PM

Document Has Been Signed on 04/24/2023 01:30 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:
04/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Danielle Loboda and Craig PardueTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the annual inspection. The initial inspection was conducted on 04/14/2023. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant & Environment Safety: This facility consists of (7) small buildings. All buildings have smoke alarms and carbon monoxide detectors which were tested and operable. Fire extinguisher appeared to be full and located in each building (service date 09/09/2022). Signal System in every room (tested and operable). The main signal system notification panel is located in the main building. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water supply measured within regulation requirements (107.0* to 115.0*).

Food Service: Sufficient food supplies of 2-day perishable and a week of non-perishable items. Per Co-Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside the shed). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and are bubbled packed and stored inside the medication cabinet and med cart located inside the main building. LPA reviewed medication for C-1 through C-5. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Disaster Preparedness: The facility does not have a complete Emergency Disaster and Mass Casualty Plan. Deficiency noted and will be cited on LIC 809D.
**Exit interview, appeals rights and a copy of this report was provided to Craig Pardue.**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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Document Has Been Signed on 04/24/2023 01:30 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 04/24/2023 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTHSIDE MANOR
FACILITY NUMBER: 191502984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record view, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Facility Administrator to complete and submit to LPA Irra by POC due date of 05/08/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
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