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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001252
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:39:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/19/2021 01:39 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BUBBE & ZAYDE'S PLACE IIFACILITY NUMBER:
306001252
ADMINISTRATOR:CURKIN, BONNIEFACILITY TYPE:
740
ADDRESS:1533 E. 20TH ST.TELEPHONE:
(714) 542-3939
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Staff Dalia Castillo and Vanity Vieyra and House Manager Juanita Gonzalez.TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Dalia Castillo and Vanity Vieyra. Administrator Shimon Cagan was contacted via telephone. He had just left the facility and gave House Manager Juanita Gonzalez permission to sign the report. The focus of the visit was Infection Control. LPA toured the facility with Ms. Castillo and Vieyra and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Bonnie Curkin expires on 10/11/22 and 11/21/21 for Shimon Cagan. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were resting in their rooms and others having lunch. Social distancing and masks for staff were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply of medications.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as Staff Testing and Masking Guidelines. All staff and residents have received their 3rd booster shot according to staff present. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to House Manager Juanita Gonzalez.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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