306005182-10-9-2020-22-AS-VCOK-C2QVUV-20210505164519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 10/09/2020
Date Signed: 10/09/2020 06:17:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200203111912

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: 80	DATE:	10/09/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Monica Yu		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

* There is insufficient staff to care for the residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Lydia Martinez & Sean Haddad made an unannounced visit to this facility to deliver findings on above allegation. LPA's met with Operations Manager Hyo "Monica" Kim and reason for visit was discussed. Assistant Administrator Erik Doan arrived shortly after.

During the investigation, interviews were conducted with residents, a witness, and staff. Additionally, copies of facility’s staff schedule for the months of January 2020 and February 2020 were obtained and reviewed.

The investigation into allegation that there is insufficient staff to care for the residents revealed the following: On 02/12/20, during the investigation inspection LPA observed the following personnel: 4 Caregivers, 1 Med-Tech, 1 Housekeeper and 1 Laundry staff for 113 residents. Out of 113 residents, 43 residents were placed in the Memory Care with 2 Caregivers on duty while the remaining 2 Caregivers were assisting 70 residents in the Assisted Living side. es of the report and to return a signed copy to LPA.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 22-AS-20200203111912

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/09/2020

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
26
27
28
29
30
31
32

On 01/13/20, LPA’s observed only 1 Caregiver and one volunteer on the floor with 29 residents in Memory Care. During 01/29/20 visit, LPA’s observed 40 residents in the Memory Care with 2 Caregivers on duty.

Interview with Resident 1(R1), Resident 2 (R2), and Resident 3 (R3) stated to LPA’s it takes more than a week for a shower due to the lack of staff. Resident 4 (R4) stated last shower R4 received was on 01/17/2020 because of no staff. R1 and R2 stated residents are made to wait in the dining room for about an hour due to having no staff to assist them back to their room. Resident 3 stated it was 10:03a.m. and R3 still had not had breakfast and blames it on the lack of staff. Interview with a witness stated Resident (R5) did not receive a shower for two weeks and diaper is not changed when needed all due to not having enough staff to care for the needs of the residents.

Based on review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. See LIC9099D for cited deficiency per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted with Administrator Hope Pak and a copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 22-AS-20200203111912

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/13/2020 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: LPA's observation, staff schedules and	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	interviews with staff, residents, and a witness corroborate facility did not provide adequate number of competent staff to meet the needs of the residents. Residents diapers are not changed when needed, residents are not receiving their shower as scheduled; and are made to wait in dining area for more than an hour before and after a meal due to facility	8 9 10 11 12 13 14	being understaffed. This poses immediate threat on health and safety of residents.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3