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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001360
Report Date: 03/02/2023
Date Signed: 03/03/2023 12:36:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220524112748
FACILITY NAME:BUBBE & ZAYDE'S PLACE IIIFACILITY NUMBER:
306001360
ADMINISTRATOR:BONNIE CURKINFACILITY TYPE:
740
ADDRESS:1530 E. 21ST STREETTELEPHONE:
(714) 543-3939
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 6DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Shimon CaganTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident received injuries while in care due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Shimon Cagan to discuss the complaint findings for the above allegation. The investigation was investigated by the Department and consisted of interviews with Administrator Shimon Cagan, staff and witnesses as well as documentation from the facility file. The following was determined:

Resident #1(R1) was admitted into the facility on March 9, 2022. R1 has Cognitive Impairment and can be combative. R1 needs assistance with medication and all Activities of Daily Living. R1 was a fall risk and the facility staff were made aware of this at the time of admission. A bed alarm was put into place to alert staff.

On May 19, 2022, R1 fell in his bedroom. Staff #1 (S1) was in R1’s room helping another resident; however his back was turned and he did not witness R1 have a ground level fall. When S1 saw R1 had fallen, he took appropriate steps to call 911 and immediately notify his supervisor.

Continued-
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20220524112748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 306001360
VISIT DATE: 03/02/2023
NARRATIVE
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Based on the information gathered during the investigation, there is no evidence to indicate that there was neglect/lack of supervision of R1. The allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Shimon Cagan and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2