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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203035
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:39:34 AM

Document Has Been Signed on 03/28/2024 11:39 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alvin Picettay and Angela Kirtman HarrisTIME COMPLETED:
11:45 AM
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On 03/28/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection at 10:30 AM. LPA Martinez met with Alvin Picettay and Angela Kirtman Harris and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six ambulatory clients. There are currently 6 residents who reside at this facility.

The LPA Martinez toured the facility with Angela Kirtman Harris on 03/28/2024 at 11:30 AM.

LPA Martinez conducted a file review, and staff and resident files were maintained. LPA Martinez reviewed 1 medication file, and the medication administration record (MAR) was complete. The facility has a natural disaster plan and infection control plan. The last fire drill was on 03/20/2024, and fire extinguisher is in good repair. The facility bedrooms and bathrooms are sanitary and clean. The facility has an adequate food supply. The facility swimming pool is gated and locked. The emergency exit gate is clear of debris and in good repair. The facility water temperature measured at 106 degrees, and the facility temperature measured at 68 degrees.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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