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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001844
Report Date: 06/30/2021
Date Signed: 07/01/2021 11:03:49 AM

Document Has Been Signed on 07/01/2021 11:03 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 & ZAYDE'S PLACE IVFACILITY NUMBER:
306001844
ADMINISTRATOR:SHIMON CAGENFACILITY TYPE:
740
ADDRESS:1529 E. 20TH STREETTELEPHONE:
(714) 543-3937
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 6DATE:
06/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Seth CurkinTIME COMPLETED:
12:30 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) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Mireya Vazquez and Juana Gonzalez. LPA explained the purpose of the visit and Administrator's Shimon Cagan and Seth Curkin were called. Mr. Curkin arrived shortly after LPA.

During the visit LPA toured the facility inside and out with Seth Curkin. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Shimon Cagen that expires 11/21/21 . Seth Curkin also has an Administrator Certificate that expires 8/21/22. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained ample supplies of paper towels and soap. Hand sanitizer, wipes and gloves were also present.

LPA observed outside visitation area with ample shading. Residents were watching a movie and having lunch. Licensee has required Mitigation plan and Emergency Disaster Plan. Emergency food and water supply were also present. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times.

No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Seth Curkin.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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