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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203035
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:50:42 PM

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: 5DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angela Kirtman, AdministratorTIME COMPLETED:
01:15 PM
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On 07/22/2021 at 11:15am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Angela Kirtman regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 11:45am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. 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 73 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 113.2 and 111.7 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 is hardwired. LPA observed carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on September 11, 2020. Emergency Disaster Plan was last posted on 09/01/2020. Mitigation plan observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 05/23/2021.


Continued on 809C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 397203035
VISIT DATE: 07/22/2021
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The following forms to be updated and submitted to CCLD by 07/29/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

No deficiencies cited.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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