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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203036
Report Date: 03/16/2023
Date Signed: 03/30/2023 09:00:18 AM

Document Has Been Signed on 03/30/2023 09:00 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PICKETTAY CARE HOME 1FACILITY NUMBER:
397203036
ADMINISTRATOR:ANGELA KIRTMAN HARRISFACILITY TYPE:
735
ADDRESS:2233 BIG OAK COURTTELEPHONE:
(209) 565-5252
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 6CENSUS: 6DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Angela KirtmanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Angela Kirtman. The administrator currently holds a certificate (#6012387738) that expires on 01/09/2024. The facility’s fire clearance was approved for 6 ambulatory residents..

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by clients and 0 bedroom are occupied by 0 staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 70-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 116-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors are hard wired to the fire department and carbon monoxide was in operating condition during visit. Fire extinguisher was last serviced on March 24, 2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/03/2023.

Staff records were reviewed, and all staff have criminal record clearance or a criminal record exemption and holds a current first aid certificate.

No deficiencies were cited during this inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
Amendment made on 03/17/23 to add in forgotten signatures.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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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