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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200336
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:48:29 PM

Document Has Been Signed on 08/17/2022 03:48 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:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gerald Caluag, CaregiverTIME COMPLETED:
04:00 PM
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On 08/17/2022 at 2:20pm Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct infection control inspection LPA met with Caregiver, Gerald Caluag and explained the purpose of the visit. Administrator arrived at approximately 3:15pm.

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility staff were observed wearing masks. Facility Administrator will purchase 30-day supply of PPE to be maintained at a central location and easily accessible for staff. Facility has a infection control plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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