306005874-5-31-2024-22-AS-EKIM-D5SVYX-20240531165153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005874
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:53:06 PM

Document Has Been Signed on 05/31/2024 04:53 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BUBBE AND ZAYDE'S PLACE, INC		FACILITY NUMBER:	306005874
ADMINISTRATOR/ DIRECTOR:	CURKIN,SETH&CAGAN,SHIMON		FACILITY TYPE:	740
ADDRESS:	1541 EAST 20TH STREET		TELEPHONE:	(714) 543-3939
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY: 6		CENSUS: 5	DATE:	05/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Juana Gonzalez		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On May 31, 2024 at 1:15PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Supervisor (SV) Juana Gonzalez and explained the purpose of the visit. Administrator Shimon Cagan was contacted over the phone to explain he could not attend today's visit.

The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, an attached garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with SV Gonzalez. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, and Resident Room 3. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.9 and 115.1 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility.

LPAs Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has two (2) fire extinguishers that are charged and they were all serviced on March 12, 2024, smoke detectors, and carbon monoxide detectors were operable. A working telephone (657-210-4114) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUBBE AND ZAYDE'S PLACE, INC	FACILITY NUMBER: 306005874
	VISIT DATE: 05/31/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA Kim reviewed the facility’s plan of operation, infection control plan, and emergency and disaster plan..

LPA Kim conducted an audit of all resident files (R1-R5), staff files (S1-S3), and medication and medication administration record. LPA Kim conducted 2 staff interviews and no residents because all residents were out in the community.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6).

An exit interview was conducted, and a copy of this report was provided to Supervisor Juana Gonazalez.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2024 04:53 PM - It Cannot Be Edited

Created By: Edward Kim On 05/31/2024 at 04:19 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUBBE AND ZAYDE'S PLACE, INC	FACILITY NUMBER: 306005874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA Kim observed in the record review of R2 the medical assesment was done on March 13, 2023. This poses a potential health, safety or personal rights risk to person in care.
	POC Due Date: 06/10/2024
	Plan of Correction
1 2 3 4	Licensee states they will complete POC with a current medical assessment physician's report to CCLD via email to edward.kim@dss.ca.gov by June 10, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lourdes Montoya

LICENSING EVALUATOR NAME:

Edward Kim

LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

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