306005182-4-5-2021-22-AS-SHAD-BZSVYD-20210405165059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 04/05/2021
Date Signed: 04/05/2021 04:51:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BOK SENIOR HOTEL		FACILITY NUMBER:	306005182
ADMINISTRATOR:	PAK, HOPE		FACILITY TYPE:	740
ADDRESS:	1100 E WHITTIER BLVD		TELEPHONE:	(714) 529-1697
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 82	DATE:	04/05/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Monica Kim		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/5/21, Licensing Program Analyst (LPA) Sean Haddad made an unannounced Plan of Correction inspection to verify correction of deficiencies issued during the inspection conducted on 3/8/21 via tele-visit due to COVID-19 and for precautionary measures. LPA met with Operating Manager (OM) Monica Kim and explained the reason for today’s inspection. During this inspection, the LPA observed the following: Type B Violations (POC due 3/15/21) 4. Deficiency cited under Title 22 Regulation 87307(a)(3)(D) pertaining to restrooms missing toilet paper, soap, etc. has NOT been cleared. LPA was provided lists and photos of corrections. However, during today’s inspection, LPA observed multiple bathrooms missing toilet paper, soap, etc., including Rooms 202, 208, 220, 227, 256, and 259. Civil penalties assessed. 5. Deficiency cited under Title 22 Regulation 87555(b)(6) pertaining to the menu not being posted has been CLEARED. LPA was provided with copies of the menu. During today’s inspection, LPA visually confirmed the menu for the Korean option was posted. As of today’s inspection, the POC has been properly cleared. Type B Violations (POC due 3/22/21) 1. Deficiency cited under Title 22 Regulation 87307(a)(3)(E) pertaining to broken closets has been CLEARED. LPA was provided lists and photos of repairs as well as purchase orders for replacements. During today’s inspection, LPA visually confirmed the corrections in affected Rooms 127, 120, 116, 223, 224, 209, 233, 227, 253, and 207. As of today’s inspection, the POC has been properly cleared. (continued)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BOK SENIOR HOTEL	FACILITY NUMBER: 306005182
	VISIT DATE: 04/05/2021

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2. Deficiency cited under Title 22 Regulation 87219(f) pertaining to the lack of a full-time activity coordinator has NOT been cleared. LPA was provided a statement indicating a full-time activity coordinator had been appointed as well as logs of activities conducted. However, during today’s inspection, OM admitted that OM is filling the role of the activity coordinator on a part-time basis and that the facility still does not have a full-time activity coordinator as required. Civil penalties assessed.

3. Deficiency cited under Title 22 Regulation 87705(c)(5) pertaining to reassessments and reappraisals was addressed. During today’s inspection, LPA confirmed OM’s understanding, reviewed 9 recent reassessments and 2 recent reappraisals. LPA observed significant progress has been made and OM agreed to send a list of residents whose assessments/reappraisals have been completed or are scheduled to LPA by 4/6/21.

4. Deficiency cited under Title 22 Regulation 87707(a)(1) pertaining to dementia training has been CLEARED. LPA was provided a dementia training plan that includes 6 hours of training through the Alzheimer’s Association Training and Education Center. During today’s inspection, LPA confirmed the details of the training plan with OM and confirmed the care staff are being trained under the new plan. Licensee has complied with the terms of the POC by POC due date.

Civil penalties are being assessed. See LIC421FC. An exit interview was conducted with Facility representative via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to send a signed copy by email.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC809 (FAS) - (06/04)

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