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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200062
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:22:40 PM

Document Has Been Signed on 01/22/2025 02:22 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/
DIRECTOR:		CRYSTAL BAZILE WILKINSFACILITY TYPE:
735
ADDRESS:3139 HENDERSON DRIVETELEPHONE:
(510) 759-1713
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 4CENSUS: 3DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:CRYSTAL BAZILE WILKINS, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 01/22/2025 at 09:45 am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year required inspection. LPA met with Crystal Wilkins, Administrator. The Administrator currently holds a certificate #7012513735 that expires on 08/15/2026. The facility’s fire clearance was approved for four (4) ambulatory clients.

LPA toured the facility with Crystal Wilkins, including but not limited to bedrooms, bathroom, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which three (3) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 109.6 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/25/2024. Fire drill was last conducted on 08/1/2024. Emergency Disaster Plan was last posted no date or signature. First aid kit was observed to be complete.

LPA reviewed three (3) staff records and three (3) resident records and all are complete.


Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 5
Document Has Been Signed on 01/22/2025 02:22 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/22/2025 at 12:15 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: WILKINS RESIDENTIAL BOARD & CARE
FACILITY NUMBER: 079200062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(4)
Food Service
(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.

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 a small and large refrigerator dirty which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to clean both small and large refrigerators cleaned and submit photos to the Department by the POC date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not conducting quarterly drills which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to conduct a drill and provide the Department with a sign in sheet with all attendees by the 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/22/2025 02:22 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/22/2025 at 12:15 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: WILKINS RESIDENTIAL BOARD & CARE
FACILITY NUMBER: 079200062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

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 not having an updated Emergency Disaster Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to update, post and provide the Department with a copy of the updated Emergency Disaster Plan by the POC date.
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times.

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 room #2 doors, kitchen cabinets and kitchen table dirty. Slow draining sink in the resident’s bathroom and urine smell which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to clean and sanitize bathroom, doors, and kitchen cabinets, repair residents bathroom sink and provide photos to the Department by the 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


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: 01/22/2025
NARRATIVE
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Continue from LIC 809

The following forms to be updated and submitted to CCLD by 1/31/2025:
  • LIC610D Emergency disaster plan (signature page)
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • Surety bond
  • LIC400 Affidavit Regarding Client/Resident Cash Resources

LPA observed the following deficiencies:
  • At 10:16am, LPA observed the residents bathroom sink, shower and bottom of toilet dirty with a urine smell.
  • At 10:18am, LPA observed residents bathroom sink is slow draining.
  • At 10:22am, LPA observed residents room #2 door and wall are dirty.
  • At 10:27am, LPA observed kitchen table was cluttered and dirty.
  • At 10:50am, LPA observed kitchen cabinet doors dirty.
  • At 10:55am, LPA observed small refrigerator dirty.
  • At 10:59am, LPA observed large refrigerator dirty.

The deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/22/2025 02:22 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/22/2025 at 01:54 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: WILKINS RESIDENTIAL BOARD & CARE
FACILITY NUMBER: 079200062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80073(a)

(a) All facilities shall have telephone service on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having a landline phone at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to order landline phone service and provide the Department with the phone number by the POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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