306004445-1-17-2025-22-AS-BLOZ-DCZVL3-20250117153117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004445
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:31:26 PM

Document Has Been Signed on 01/17/2025 03:31 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 VII		FACILITY NUMBER:	306004445
ADMINISTRATOR/ DIRECTOR:	SHIMON CAGAN		FACILITY TYPE:	740
ADDRESS:	1542 E. 21ST STREET		TELEPHONE:	(714) 928-5030
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Administrator Shimon Cagan		TIME VISIT/ INSPECTION COMPLETED:	03:47 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Administrator Seth Curkin after explaining the purpose for the visit. Administrator (AD) Shimon Cagan was notified and later arrived to assist with the inspection. LPA observed that Administrator Shimon Cagan has a valid Administrator certificate which expires on November 21, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for three. The facility is a single-story home with five private resident bedrooms, three resident bathrooms, two of which are shared, a living room, a den, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed five residents in care, none of which are receiving hospice care, and two caregiver staff present. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 105.1 and 108.5 degrees Fahrenheit. LPA observed the kitchen has a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed a fireplace in the wall connecting from the dining room to the living room. The fire place is adequately screened and is not operational. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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: 01/17/2025

NARRATIVE

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Fire extinguishers are located in the dining room and hallway by the resident rooms. Fire extinguishers were observed to be charged and serviced as of March 12, 2024. LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on September 9, 2024. The centrally stored medication is kept in a locked closet by the dining room. LPA observed the First Aid kit has all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage. LPA observed chemicals and toxins stored in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the westside and eastside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed the five resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed five residents’ medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility.

Based on today's observations, one deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Seth Curkin. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/17/2025 03:31 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care. Based on file review, LPA observed the facility conducted their last emergency disaster drill on September 9, 2024.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	AD agreed to conduct in house emergency disaster training with all staff. AD will submit proof of training to LPA via email or fax by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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