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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203035
Report Date: 03/17/2023
Date Signed: 03/17/2023 01:17:32 PM

Document Has Been Signed on 03/17/2023 01:17 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
SACRAMENTO AC/SC, 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:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angela Kirtman, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Renee Campbell made an unannounced Annual 1-Year Required visit on this date 03/17/2023. LPA met and toured with Shontell Upton, House Manager and Administrator, Angela Kirtman. The administrator currently holds a certificate (#6012387735) that expires on 01/09/2024. The facility’s fire clearance was approved for 03/22/2007.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. A comfortable temperature is maintained at 69 degrees Fahrenheit. The hot water temperature is maintained at 114 degrees Fahrenheit. All outdoor and indoor passageways were kept free from obstruction. Rooms were furnished appropriately. There was an adequate supply of toiletries, hygiene supplies, and extra linens. LPA observed clients’ linens were in good repair. There is a minimum of 7-day nonperishables and 2-day perishable foods.

The last fire drill was March 13th, 2023. Fire extinguishers, smoke detectors and carbon monoxide were checked. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the clients’ needs. All staff have criminal record clearance and are associated to the facility. LPA reviewed clients’ files.

No deficiencies were cited during this inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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