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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200062
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:05:58 PM

Document Has Been Signed on 01/31/2024 01:05 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:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Noah Wilkins, Administrator asset.TIME COMPLETED:
02:00 PM
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On 01/31/2024 at 11:00AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an annual required inspection. LPA met with administrator and explained the purpose of the visit. Administrator Noah Wilkins has a current ARF certificate # 6062861735 with effective dates 1/12/2023 until 4/17/2025 and Crystal Wilkins Administrator certificate # 6041671735.

LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Personal rights. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in storage cabinets. Chemicals and sharps were observed locked in cabinets. Comfortable temperature is maintained at 71 degrees F. Hot water temperature was measured at 109.9 degrees F. Facility has a mitigation plan in place. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 01/07/2023. Fire & earthquake drills are conducted each month. LPA reviewed 3 staff and 3 client files all complete.

continue on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WILKINS RESIDENTIAL BOARD & CARE
FACILITY NUMBER: 079200062
VISIT DATE: 01/31/2024
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continue from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/07/2024:

· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

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: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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