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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412143
Report Date: 08/05/2021
Date Signed: 08/05/2021 10:26:43 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:M.A.M. FAMILY HOME IIFACILITY NUMBER:
366412143
ADMINISTRATOR:JDELGADO/MDELAROSAFACILITY TYPE:
740
ADDRESS:1395 N SAN ANTONIO AVETELEPHONE:
(909) 579-0060
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 0DATE:
08/05/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joy DelgadoTIME COMPLETED:
10:36 AM
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Licensing Program Analysts (LPA's) Melody Brown and Natalie Gayoso conducted an announced visit to conduct a final walk through of the facility prior to closure. The Department was notified of the facility closure by the Administrator Joy Delgado on 07/21/2021.

LPA's toured the facility, no personal property of residents previously in care. The Administrator surrendered original license and sent to Sacramento. Administrator was informed the license is no longer active as of today, 08/05/2021. Ms. Delgado was informed that care and supervision can no longer be provided unless an application is submitted for licensure in the future.

Exit interview was conducted and a copy of this report was provided to Ms. Delgado.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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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