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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003949
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:41:41 PM


Document Has Been Signed on 07/21/2022 03:41 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 VFACILITY NUMBER:
306003949
ADMINISTRATOR:SHIMON CAGANFACILITY TYPE:
740
ADDRESS:1534 21ST STREETTELEPHONE:
(714) 542-0382
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 3DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Shimon Cagcan TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Angeles Lazaro and Administrator Shimon Cagan and stated the purpose of this visit.

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

At about 02:23 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 3 residents in care and three staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms 2 of which were vacant. 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. The upstairs portion of the facility is for staff only and is used as a home office. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 112.2 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were 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 and is kept locked and used for storage and emergency supplies. Both washer and dryer are kept outside in the den area of the facility. Kitchen was in good repair with medications kept locked separately. 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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 V
FACILITY NUMBER: 306003949
VISIT DATE: 07/21/2022
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For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Shimon Cagan and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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