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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200062
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:09:03 PM

Document Has Been Signed on 06/22/2022 12:09 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:WILKINS RESIDENTIAL BOARD & CAREFACILITY NUMBER:
079200062
ADMINISTRATOR:CRYSTAL BAZILE WILKINSFACILITY TYPE:
735
ADDRESS:3139 HENDERSON DRIVETELEPHONE:
(510) 759-1713
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 4CENSUS: 3DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Crystal Bazile Wilkins, AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 06/22/2022 at 9:45 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Crystal Bazile Wilkins and explained the purpose of the visit.

Upon entry, LPA temperature was checked by Administrator. LPA toured facility including but not limited to bedrooms, bathroom, kitchen, common areas, and outdoor areas. LPA 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, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 10:20am, LPA observed side gate locked.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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Document Has Been Signed on 06/22/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 06/22/2022 at 11:51 AM
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: WILKINS RESIDENTIAL BOARD & CARE
FACILITY NUMBER: 079200062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(7)
(7) Not to be locked in any room, building, or facility premises by day or night.

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 the side gate locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Administrator removed locked during visit. deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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