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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203035
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:28:37 PM

Document Has Been Signed on 03/16/2022 04:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PICKETTAY CARE HOME 2FACILITY NUMBER:
397203035
ADMINISTRATOR:ANGELA KIRTMAN HARRISFACILITY TYPE:
735
ADDRESS:3963 PALAZZO COURTTELEPHONE:
(209) 957-5401
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Angela Kirtman, Administrator TIME COMPLETED:
11:35 AM
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On 03/16/2022 at 9:20 AM, LPA T. White arrived unannounced to conduct a Required 1-year annual inspection. At 10:05 AM LPA met with Administrator, Angela Kirtman and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. This facility had a pool in the backyard with slide. Pool is fenced and locked. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.2 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

LPA observed smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on October 25,2021. The facility submitted a LIC 808 mitigation plan, which was approved. First aid kit was observed to be complete. Fire drill was last conducted on 03/04/2022. LPA reviewed 2 staff records and 2 client files.

The following forms to be updated and submitted to CCLD by 03/25/2022:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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