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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603407
Report Date: 09/19/2023
Date Signed: 09/19/2023 05:20:33 PM

Document Has Been Signed on 09/19/2023 05:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NU LIFE, THEFACILITY NUMBER:
198603407
ADMINISTRATOR:DUNGCA, ROMMELFACILITY TYPE:
735
ADDRESS:1159 S. ARDMORE AVETELEPHONE:
(213) 383-0504
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 27CENSUS: 24DATE:
09/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Rommel Dungca - AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena generated this Case Management-Deficiencies report in conjunction with complaint control #28-AS-20230918114141. This report is being generated to address deficiency observed during the visit that is not related to the complaint allegation.

While conducting a tour of the facility with the Administrator, LPA observed that Client #1 (C1) bed mattress in Room #2 has lice. Administrator witnessed the lice and LPA was given the permission to take photos of the mattress.

Based on observation, the deficiency is issued on the attached LIC809D. An exit interview was conducted, and a copy of the report and appeal rights were issued to Administrator, Rommel Dungca.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 2
Document Has Been Signed on 09/19/2023 05:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/19/2023 at 03:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NU LIFE, THE
FACILITY NUMBER: 198603407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2023
Section Cited
CCR
80087(a)(1)

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80087 Buildings and Grounds..(a)The facility shall be clean, safe, sanitary...for the safety and well-being of clients,.. (1)The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
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Administrator agreed to replace the mattress and will purchase lice shampoo to be used by clients who are infested with lice. Administrator will submit proof of photos of the items to CCL/LPA by POC due date.
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Based on observation, the client's mattress in Room #2 has lice which posed a potential health, safety, and personal rights to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
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