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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001844
Report Date: 05/17/2022
Date Signed: 05/18/2022 07:51:24 AM

Document Has Been Signed on 05/18/2022 07:51 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:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Shimon Cagan and Staff Juana GonzalezTIME COMPLETED:
11:30 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 Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Shimon Cagan and Staff Juana Gonzalez. LPA toured the facility with Mr. Cagan and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. There is 1 entrance point for all the homes. LPA's temperature was taken upon arrival and a sign in sheet was available with a survey. Facility has required Department postings inside and outside the facility. The Administrator for this facility is Shimon Cagan and his Administrator Certificate expires on 11/21/23. Resident bedrooms met regulation guidelines. Bathrooms 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. Smoke and carbon monoxide detectors were operational and fire extinguishers were present. LPA observed an outside visitation area with ample shading. Residents were next door at the Chapel watching a movie. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication closet for resident medication and files.

During the visit, LPA observed staff wearing a mask. LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of masks and frequent hand washing for staff. Administrator is reminded to review Department PINS and to keep updated on Department Requirements regarding Infection Control, Testing and Masking Guidelines.

No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Juana Gonzalez.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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