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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001252
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:31:52 PM

Document Has Been Signed on 11/03/2022 12:31 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
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:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Shimon CaganTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Shimon Cagan and stated the purpose of this visit.

The facility is a single-level structure and licensed for six non-ambulatory with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Hospice.

At about 11:13 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms 1 of which was shared room. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 111.7 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Kitchen was in good repair with cleaning supplies and sharp items inaccessible to residents in care. Medications were kept locked separately. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Facility offers a 2-car garage that is kept locked and used for storage with emergency supplies, an extra freezer and refrigerators. Laundry room contained an operational washer and dryer with detergents kept locked.

For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Outdoor patio contained a water fountain and well maintained plants and a tree.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306001252
VISIT DATE: 11/03/2022
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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Administrator Shimon Cagan and copy of this report was explained and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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