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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502984
Report Date: 03/14/2025
Date Signed: 03/14/2025 12:30:56 PM

Document Has Been Signed on 03/14/2025 12:30 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/
DIRECTOR:		JAMES (GARY) PARDUEFACILITY TYPE:
735
ADDRESS:820 EAST GRAND AVENUETELEPHONE:
(909) 623-7305
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 38CENSUS: 25DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Craig Pardue and Danelle LobodaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Craig Pardue (Facility Administrator). LPA explained the purpose of today's visit. Danelle Loboda (Assistant Administrator) arrived at approximately 8:40 A.M. and assisted with this visit.

This 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 (CARE) tools for the visit today and observed the following:



Infection Control: Facility has an Infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detectors tested and operable. Fire extinguishers were last serviced 12/11/24 (one in each building including (1) in kitchen and (1) in laundry room). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water temperature measured as follows: 114.0* in building #1, 112.0* in building #2, 115.0* in building #3, 109.0* in building #4, 110.0* building #5, 112.0* in building #6 and 114.0* in building #7.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of (18) and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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 2
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: 03/14/2025
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Personnel Records-Training: LPA reviewed staff files for (S-1) through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #5 (C-5). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The 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 locked inside a medication cart. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Ms. Loboda, there are (0) clients with a restrictive health plan, (0) client utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place. Last fire drill was conducted on 02/25/25.

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

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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