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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603407
Report Date: 02/27/2026
Date Signed: 02/27/2026 02:09:09 PM

Document Has Been Signed on 02/27/2026 02:09 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/
DIRECTOR:		DUNGCA, ROMMELFACILITY TYPE:
735
ADDRESS:1159 S. ARDMORE AVETELEPHONE:
(213) 383-0504
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 27CENSUS: 26DATE:
02/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:27 AM
MET WITH:Anie Delen, Office Administrator TIME VISIT/
INSPECTION COMPLETED:
02:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted the annual inspection. LPA arrived unannounced and met with Marlow Cacpal, Med-Tech and Hazel Hipolito, DSP/dietary Cook who allowed entry. Anie Jaen Delen Office Administrator arrived a short time later and assisted with the visit. The facility is licensed to serve a total of 27 adults, of which 27are ambulatory.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Fire Drills are conducted every three months; the last fire drill was conducted on 01/08/2026. Emergency Disaster/ Earthquake Drills are conducted every 3 months, and the last one was conducted on 01/08/2026 Facility staff conducts every 3 months



Physical Plant & Environment Safety: Facility is licensed for residents 18 to 59 years old. The facility has a fire clearance approved for twenty-seven (27) ambulatory clients. There are (15) client bedrooms, all but 2 are shared rooms. 5 bathrooms, 3 with showers, living room, activity room, dining room, kitchen, office area, laundry room, detached garage used as storage.(continue on 809C)
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/27/2026 02:09 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/27/2026 at 01:43 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation, two rooms did not have batteries in the carbon monoxide detectors the licensee did not comply which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
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Licensee will check all 15 rooms and certify that all rooms have working carbon monoxide detectors and send proof to LPA by POC date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the water measured between 106.5 - 128.7 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
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licensee will adjust water and keep a log for 3 days and send to LPA as proof of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 198603407
VISIT DATE: 02/27/2026
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(continued from 809) Facility did not have some operable smoke and carbon monoxide combo detectors. They were missing batteries. Knives, cleaning solutions, and disinfectants are locked in the kitchen cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms. The hot water temperature in the bathrooms measured 106.5-137.7 degrees F, which is not within the required range of 105-120 degrees F. Licensee adjusted water temperature during visit. Facility has fire clearance and fire alarm was tested during visit. There is a hole in wall of room 5 that requires repair.
Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained in a secure location within the staff office. LPA reviewed four (4) staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Current First Aid/CPR/AED and sufficient on-going training. Rommel Dunga, Administrator Certificate expires on 07/01/2027
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for its ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication do have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked room and are in their original containers. LPA reviewed 4 client’s medications logs, and medication is administered as ordered by physician.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility Administrator will update LIC610 to show staff training on disaster preparedness.
Emergency Intervention: Clients do not require the use of restraints or de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Copy of report, technical violations and appeal rights provided.
Exit interview was held, a copy of the report provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026
LIC809 (FAS) - (06/04)
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