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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200336
Report Date: 08/03/2024
Date Signed: 08/03/2024 04:00:57 PM


Document Has Been Signed on 08/03/2024 04:00 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:
08/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gilbert Caluag, CaregiverTIME COMPLETED:
04:05 PM
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On 8/32024 at 2:00pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Gilbert Caluag. Administrator Tina Djudjo, arrived at 2:25pm, and LPA explained the purpose of the visit. The Administrator currently holds a certificate (#6057150740) that expires on 9/14/2024.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and three (1) bathrooms. One (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 122.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/20/2023. Emergency Disaster Plan was last posted on 10/16/2020. First aid kit was observed to be complete. Fire drill was last conducted on 4/5/2024.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 079200336
VISIT DATE: 08/03/2024
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Continued from LIC809.

Four (4) staff records were reviewed and current. All five (5) resident records were reviewed and complete.

LPA requested the following documents to be submitted to CCLD by 8/12/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2024
LIC809 (FAS) - (06/04)
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