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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502984
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:06:48 AM

Document Has Been Signed on 04/29/2022 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 30DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Craig Pardue-Facility AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection. LPA met with Craig Pardue (Facility Administrator) and discussed the purpose of today's visit.

Facility is a single story home located in a residential area. The property has 7 buildings. All clients receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility. Signs to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. These items are stored inside the office, main front house and supply storage room (behind main house).
  • Restrooms have hand soap and paper towels. Hand sanitizers only in common areas in which staff supervise.
  • Food supply observed. There are (8) refrigerators/freezers throughout the premises. Non-perishable food is stored in the kitchen pantry and a storage shed in the back of the property.
  • Per Facility Administrator, (13) staff are vaccinated (10) of which have their booster. (3) out of the (13) staff have their booster pending.
  • Per Facility Administrator, all clients are fully vaccinated including the booster.
  • Medication reviewed for (3) clients (C-1 through C-3).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.


Exit conducted, a copy of this report and appeal rights provided to Craig Pardue
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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