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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004445
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:11:08 PM


Document Has Been Signed on 06/07/2024 04:11 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 VIIFACILITY NUMBER:
306004445
ADMINISTRATOR:SHIMON CAGANFACILITY TYPE:
740
ADDRESS:1542 E. 21ST STREETTELEPHONE:
(714) 928-5030
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Shimon Cagan-Licensee/AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to conduct the required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA met with Licensee/Administrator Shimon Cagan and stated the purpose of the visit.

The facility is a single level structure located in a residential neighborhood and licensed to operate for six (6) non-ambulatory and maintains a hospice waiver of three (3). For this visit, there is one (1) resident under hospice care.

LPA Cho toured the interior and exterior of the facility. All rooms were inspected including five resident bedrooms. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each residents' personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 114.0, 115.5, and 115.9 degrees Fahrenheit.

LPAs observed the facility to be clean and sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to the residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. The facility has two fire extinguishers that were charged and serviced on 03/12/2024, and the auditory devices, and smoke/carbon monoxide detectors were operational. The facility conducted a Emergency Disaster Drill on 03/14/24. A working facility telephone number, 714-543-5161, remains available. The First Aid Kit contains all the necessary elements. LPA observed the emergency disaster supplies including food/water in the garage. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BUBBE & ZAYDE'S PLACE VII
FACILITY NUMBER: 306004445
VISIT DATE: 06/07/2024
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LPA conducted an audit of four residents' files and two personnel files. No discrepancies noted with the file review. LPA conducted one interview with staff and attempted an interview with one resident. The remaining residents were participating in an activity at the time of inspection. Medications were audited for four residents. No discrepancies noted.

Based on the observations made during the 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: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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