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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502984
Report Date: 03/01/2024
Date Signed: 03/01/2024 03:30:09 PM

Document Has Been Signed on 03/01/2024 03:30 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: 24DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Administrator Craig PardueTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/01/2024. LPA Ramirez was met by Administrator Craig Pardue and explained the purpose of the visit. The facility is approved for thirty-eight (38) developmentally disabled adults, ages 18-59, of which, thirty-eight (38) may be ambulatory. All clients receive case management services provided by San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Facility is a single-story home located in a residential area. The property has 7 buildings.

Front Yard: LPA Ramirez observed front yard to be free of hazards. LPA observed a gate that encloses the front yard from the main street.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby. LPA Ramirez observed facility menu posted on wall near the stove. LPA Ramirez observed First Aid kit in nearby staff bathroom. LPA Ramirez observed signs near pantry that indicated client’s food allergies and clients who require food to be chopped or puree.

Dining Room/Sitting Area: Dining room was observed to contain several tables with plenty of seating. LPA Ramirez observed a seating area with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed nearby thermostat to read 72 degrees F. LPA Ramirez observed centrally stored medications to be stored in medication cart. Medications cart was observed to be inaccessible to clients in care. LPA Ramirez observed Personal Rights poster, Complaint or Concern poster and cough/sneeze etiquette.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed emergency call buttons in all client bedrooms. LPA Ramirez tested emergency call button in the facility main house client bedroom# 2. LPA Ramirez observed emergency call button to be operational.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SOUTHSIDE MANOR
FACILITY NUMBER: 191502984
VISIT DATE: 03/01/2024
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Bathrooms: LPA Ramirez observed nonslip mats in bathroom showers. Water temperature in all client bathrooms were measured within 105 – 120 degrees F.

Backyard: No large bodies of water were observed. LPA Ramirez observed discarded recliners and disassembled furniture in backyard area. LPA Ramirez will issue Technical Violation.

Emergency Drills: Last documented disaster drill was conducted on 02/20/2024 at 2:45pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. LPA Ramirez observed Emergency Disaster Plan.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed six (6) personnel records. First Aid Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed in personnel records. LPA Ramirez observed Administrator’s Certificate for Craig A. Pardue (6031259735) with an expiration date of 05/14/2024.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed four (4) client records. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed in client records.

No deficiencies were cited today. One (1) technical Violation was cited. Exit interview was conducted. A copy of this report and LIC 9102 was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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