<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005874
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:30:31 AM


Document Has Been Signed on 02/24/2022 11:30 AM - 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 AND ZAYDE'S PLACE, INCFACILITY NUMBER:
306005874
ADMINISTRATOR:CURKIN,SETH&CAGAN,SHIMONFACILITY TYPE:
740
ADDRESS:1541 EAST 20TH STREETTELEPHONE:
(714) 543-3939
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 3DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Supervisor Juanita Gonzalez and Administrator Shimon CaganTIME COMPLETED:
11:50 AM
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 Analysts (LPA's) Jenifer Tirre and Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA's were greeted and granted entry into the facility and explained the reason for the visit. LPA's toured facility with Supervisor Juanita Gonzalez

Facility is a single story, 3 bedroom with 2 bathroom home. There are 3 Residents in care. LPA's observed proper covid signage in entry way of facility. Facility has required Department postings. LPA's observed copy of Administrators Certificate expiring 11/21/2023. LPA's toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Proper hand washing signs posted in restrooms. Water temperature measured at 113.9 degrees . LPA's observed visitation areas with ample seating. Residents were observed relaxing in the Living room watching TV. Facility has working audible alarm system, Carbon Monoxide detectors and smoke detectors. Facility has 2 fire extinguishers fully charged. Facility has emergency food and water supply. Facility has required Emergency Disaster Plan. Facility has a secured location for resident medication and files. LPA's observed residents medications and facility has 30 days supply of medications for Residents. Residents emergency contact information and Physicians reports are current. Facility has supply of PPE supplies.


No deficiencies noted during todays visit. An exit interview was conducted with Administrator Shimon Cagan and a copy of this report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 1