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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003949
Report Date: 11/04/2022
Date Signed: 11/04/2022 01:15:40 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221101170901
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: 5DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shimon CaganTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yell at residents
Staff leave resident in bed all day
Staff are not providing adequate activities for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Michelle Reed arrived at the facility to initiate this complaint investigation. Upon arrival, LPA met with Staff Angeles Lazaro. LPA explained the purpose of the visit and discovered that R1 does not live at this facility. R1 lives at Bubbe & Zayde's II.

R1 does not live at this home, therefore, the allegations are unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. The Department has therefore dismissed the complaint.

An exit interview was conducted and a copy of this report was provided to Administrator Shimon Cagan.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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