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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191502984
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:08:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230106110555
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: 30DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Craig PardueTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for client in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegation. LPA was allowed entry by Craig Pardue. LPA explained the purpose of today's visit.

During this visit, LPA obtained a copy of the Staff Roster, Client Roster, reviewed file for C-1 and obtained relevant documentation. LPA interviewed Staff #1 through Staff #4 (S-1 through S-4). LPA attempted to interview Client #1 (C-1) and was unsuccessful as C-1 did not understand the interview questions.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230106110555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/12/2023
NARRATIVE
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Allegation: Staff did not seek medical attention for client in a timely manner.
During this investigation, LPA reviewed C-1's file and obtained relevant documentation. LPA was unable to interview C-1 as C-1 did not understand interview questions. LPA interviewed Staff #1 through Staff #4 (S-1 through S-4). Staff interviews revealed that C-1 sustained an injury (hit on top of C-1's head) while entering the transportation vehicle from C-1's day program sometime in September 2022. Per Staff interviews, C-1 has consulted with medical professionals for this injury has been given treatment and referrals to consult with a dermatologist and home health services. Staff interviews revealed that C-1 "picks on the scab" and staff redirect C-1. Staff also indicated that the treating physician's are aware of C-1 "picking on the scab". Per Staff interviews, staff continue to monitor C-1 and provide care as per physician's orders. Staff interviews and documentation reviewed does not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and appeal rights and a copy of this report was provided to Craig Pardue.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
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