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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003949
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:45:17 PM


Document Has Been Signed on 07/18/2024 03:45 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
ORANGE COUNTY RO, 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: 5DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Shimon Cagan-Licensee/AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the CARE Inspection Tool. LPA met with Licensee/Administrator Shimon Cagan and explained the reason for the visit.

The facility is a two story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory and maintains a hospice waiver for four (4). There are five residents in care during today's visit with two caregivers on duty.

LPA observed the facility to be clean and sanitary. There are five resident bedrooms and two resident bathrooms. All common areas were inspected including the attached two car garage and the sun room which doubled as a laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 113.3 and 109.2 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstructions. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers. Both were mounted, charged, and serviced on March 12, 2024. The auditory devices and dual-functioning smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency disaster supplies including food/water in the garage. Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements. A working facility telephone number, 714-542-0382, remains available.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BUBBE & ZAYDE'S PLACE V
FACILITY NUMBER: 306003949
VISIT DATE: 07/18/2024
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LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. The Administrator's Certificate for Shimon Cagan expires on November 21, 2025, August 21, 2024 for Administrator Seth Curkin, and October 11, 2024 for Bonnie Curkin.

LPA conducted an audit of five residents' files and two personnel files. No discrepancies were noted. Staff and resident interviews were conducted. Medications were audited for five residents. No discrepancies noted.

Based on the observations made during today's visit, no deficiency is being cited today. An exit interview was conducted with Licensee/Administrator Shimon Cagan, and a copy of this report was provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2