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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200336
Report Date: 08/17/2021
Date Signed: 08/17/2021 05:57:29 PM

Document Has Been Signed on 08/17/2021 05:57 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BLUE HORIZON LIVING, LLCFACILITY NUMBER:
079200336
ADMINISTRATOR:TINA MARIE DJUDJOFACILITY TYPE:
740
ADDRESS:1319 LINDEN DRIVETELEPHONE:
(925) 525-1630
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Tina Djudjo, LicenseeTIME COMPLETED:
06:10 PM
NARRATIVE
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On 8/17/2021 at 3:20PM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Gilbert Caluag and explained the purpose of the visit. Licensee, Tina Djudjo arrived 30 minutes later.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 3:40PM, LPAs observed unlocked scissors in the kitchen. Staff locked up scissors during inspection.
-At 3:50PM, LPAs observed the medication were unlocked in the kitchen drawer.
-At 4:00PM, LPAs observed cleaning supplies were stored in the same area as food supplies. Staff relocated food items to the kitchen area during inspection.
-At 4:10PM, LPAs observed facility does not have a 7-day supplies of non-perishable foods.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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Document Has Been Signed on 08/17/2021 05:57 PM - It Cannot Be Edited


Created By: Grace Luk On 08/17/2021 at 05:13 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLUE HORIZON LIVING, LLC
FACILITY NUMBER: 079200336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked scissors on kitchen counter which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Staff locked up the scissors during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above having unlocked medications in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Licensee will re-train all staff to put medications in the locked cabinets instead of the unlocked drawers. Licensee will submit staff sign in sheet to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/17/2021 05:57 PM - It Cannot Be Edited


Created By: Grace Luk On 08/17/2021 at 05:13 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLUE HORIZON LIVING, LLC
FACILITY NUMBER: 079200336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by storing cleaning supplies with food items which poses a potential health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Staff relocated the food items to the kitchen during inspection.

Deficiency cleared during inspection.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above no having a week of nonperishable food supplies which poses a potential health and safety risk to persons in care.
POC Due Date: 08/23/2021
Plan of Correction
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Licensee has agreed to purchase additional food supplies and provide a copy of the purchase receipt to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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