306001360-10-14-2022-22-AS-ETAA-CK7TFQ-20221014144156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001360
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:42:04 PM

Document Has Been Signed on 10/14/2022 02:42 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BUBBE & ZAYDE'S PLACE III		FACILITY NUMBER:	306001360
ADMINISTRATOR:	BONNIE CURKIN		FACILITY TYPE:	740
ADDRESS:	1530 E. 21ST STREET		TELEPHONE:	(714) 543-3939
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 5	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Seth Curkin		TIME COMPLETED:	02:55 PM

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with Administrator Seth Curkin and stated the purpose of this visit.

The facility is a single-level structure and licensed for six non-ambulatory with a hospice waiver for four. This facility is a Residential Care Facility for the Elderly.

At about 01:30 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed a resident in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 3 resident rooms 2 of which were shared rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 114 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Facility offers a 2-car garage is kept locked and used for storage. Laundry room was equipped with an operational washer and dryer. Kitchen was in good repair with cleaning supplies and sharp items inaccessible to residents in care. Medications are kept locked separately.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUBBE & ZAYDE'S PLACE III	FACILITY NUMBER: 306001360
	VISIT DATE: 10/14/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Seth Curkin and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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