<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601542
Report Date: 02/02/2022
Date Signed: 02/02/2022 07:40:07 PM

Document Has Been Signed on 02/02/2022 07:40 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WILKIE HOMEFACILITY NUMBER:
198601542
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:17234 WILKIE AVETELEPHONE:
(310) 538-8599
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 3CENSUS: 3DATE:
02/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:House Manager - April TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/02/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced Case Management visit. LPA met with House Manager Aprill Marshall, caregivers (S1-S2) and explained the purpose of today’s visit. The facility is licensed to serve three (3) non-ambulatory developmentally disabled clients of between the ages of 18 through 59.

LPA conducted a plant inspection.

LPA reviewed disaster records and there was no fire drill on file at the facility. On 02/02/2022, caregivers (S1-S2) stated the facility has not conducted a fire drill within the last six (6) months.

An exit interview was conducted, plan of corrections were developed with the House Manager. A copy of this report and appeals rights were provided to Aprill Marshall, the administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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
Document Has Been Signed on 02/02/2022 07:40 PM - It Cannot Be Edited


Created By: Don Senaha On 02/02/2022 at 11:53 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILKIE HOME
FACILITY NUMBER: 198601542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2022
Section Cited
CCR
80023(d)(2)

1
2
3
4
5
6
7
80023 Disaster and Mass Casualty Plan. (d) Disaster drills shall be conducted every six months. (2) The drills shall be documented and the documentation maintained in the facility for at least one year.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to complete a fire drill by 02/16/2022 and send proof.

8
9
10
11
12
13
14
Based on record reviews and interviews, the facility has not conducted a drill and does not have documentation which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2