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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401080
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:06:48 PM


Document Has Been Signed on 03/07/2022 02:06 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MILAM MANORFACILITY NUMBER:
366401080
ADMINISTRATOR:MILAM, SHIRLEY E.FACILITY TYPE:
740
ADDRESS:12787 RECHE CANYON ROADTELEPHONE:
(909) 825-8250
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY:6CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Shirley MilamTIME COMPLETED:
02:08 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit for the purpose of the facility's closure. Administrator sent a letter notifying Community Care Licensing that the effective date of the closure is 12/31/2021. LPA met with Administrator Shirley Milam.

On March 3, 2022, LPA Bueno phoned Administrator regarding the facility's. LPA was informed that there has not been any residents since 12/31/2022. The licensee is initiating this closure. The effective date of closure 12/31/2022.

LPA and Administrator inspected the facility which included the bedrooms, bathrooms, dining area, kitchen, activity, and outdoor areas. LPA confirmed there are no residents present, and there were no belongings of residents in the facility. Administrator stated that the reason of the closure is licensee relocation and sale of the property.

The administrator submitted the following during the closure plan:
1. Administrator's licence to CCL
2. Notice of Facility Closure
3. Emergency and Identification Information of the three residents, which included each residents' forwarding address

An exit interview was conducted where this report was discussed with and provided to administrator Shirley Milam.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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