306005182-6-3-2021-22-AS-MSTC-C4K2QK-20210702173605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 06/03/2021
Date Signed: 06/03/2021 04:26:07 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
01/21/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200121160538

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: 86	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Marty Oh		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff were not able to assist residents with their needs

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Operating Manager (OM) Marty Oh and explained the reason for today’s inspection.

The investigation into allegation that staff were not able to assist residents with their needs revealed the following:

During the course of the investigation, LPAs Lydia Martinez and Ruth Martinez interviewed Administrator (AD) Hope Pak, 1 witness, 1 staff member, and 6 residents, conducted an on-site visit on 1/23/20, and obtained and reviewed the following records relating to Resident #1 (R1): hospital medical records, hospice medical records, resident file, death certificate, incident report, and work orders.

(Page 1)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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 8

Control Number 22-AS-20200121160538

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: 06/03/2021

NARRATIVE

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On 1/21/20, a witness reported recently being at the facility and witnessing several residents in wheelchairs waiting for a meal. One resident began yelling that they had to go to the bathroom and began begging the witness and their relative for help. The witness told Staff Member #1 (S1) who was working at the front desk. S1 came over to the resident, picked them up by the arm pits, then dropped them back down into the wheelchair without providing the assistance the resident required. Per facility documents and interviews, S1 is a receptionist. On 1/28/21, LPAs interviewed S1 who denied picking up and dropping the resident as reported and stated they do not touch residents in such circumstances, but instead call caregivers to assist. Nevertheless, the witness’ report describes a resident who did not receive proper assistance with their needs and interviews conducted by LPAs on 1/23/20 with 5 residents corroborated the fact that the facility lacks properly trained and responsive staff to assist residents with their needs timely. Specifically, a resident reported not receiving proper care due to unresponsive staff and not being able to care for themselves and another resident reported feeling unsafe because the staff take a long time to respond to calls. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/20. The civil penalty shall be assessed until the violation is corrected.

During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Based on review of the facility's compliance history, which revealed the licensee was cited for the same violations within the last 12 months, civil penalties in the amount of $250 per repeat violation are being assessed. Civil penalties of $100 per day, per violation will accrue until the deficiencies are corrected. See LIC421FC. An exit interview was conducted and a copy of this report was left at the facility.

(Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 22-AS-20200121160538

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: 06/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/04/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	During the inspection, Licensee showed LPA documentation showing that the administrator checks on every resident twice a day with another staff member conducting tehse checks on the weekend, med techs provide meds to most residents once or twice a day, and caregivers check on most residents at least twice a day.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not provide care and supervision to the resident alleged by the witness or the 5 residents interviewed by LPAs, which poses an immediate health, safety and/or personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee stated they follow this procedure for calls: calls are received at reception, routed to caregivers via cell phone, with caregivers trained to respond immediately unless providing a shower. If it is a fall, medical emergency, other urgent issue, admin/nurse/receptionist immediately go to the resident.
	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) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
01/21/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200121160538

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: 86	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Marty Oh		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Resident hospitalized with diagnosis resulting in staff giving resident wrong medications.
Staff was rough with resident.
The hot water is not working.

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Operating Manager (OM) Marty Oh and explained the reason for today’s inspection.

The investigation into allegations that Resident hospitalized with diagnosis resulting in staff giving resident wrong medications, Staff was rough with resident, and the hot water is not working revealed the following:

During the course of the investigation, LPAs Lydia Martinez and Ruth Martinez interviewed Administrator (AD) Hope Pak, 1 witness, 1 staff member, and 6 residents, conducted an on-site visit on 1/23/20, and obtained and reviewed the following records relating to Resident #1 (R1): hospital medical records, hospice medical records, resident file, death certificate, incident report, and work orders.

(Page 1)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 22-AS-20200121160538

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: 06/03/2021

NARRATIVE

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R1 resided at the facility until they were removed by their family on 1/7/2020. The family removed R1 because they believed the facility arbitrarily stopped giving R1 their medication. The medication was stopped by the order of the hospice doctor once R1 was discharged from hospice in July 2019. The doctor’s order discharging R1 from hospice never made it to the pharmacy and the medication continued to be delivered for R1 and administered to R1 up until December 2019. The family was advised by AD that R1 was declining and R1 needed to be readmitted for hospice services. The family filled out administrative forms to get R1 on hospice but never followed through with the forms to be admitted. The family decided the best course of action was to remove R1 from the facility on 1/7/2020. The family did not inform the facility they intended to remove R1 permanently from the facility. Per AD, the facility believed R1 was going home for a few days. Per R1’s family member, R1 was suffering from abdominal pain on 1/7/2020 when R1 was removed from the facility. R1 was the transported to an Urgent Care. The Urgent Care advised R1 needed to be transported to a hospital. R1 was transported to St. Jude Hospital in Fullerton where R1 was admitted on 1/7/2020 and discharged on 1/9/2020. R1 was discharged on 1/9/2020 from St. Jude Hospital in stable condition and transferred to a skilled nursing facility (Name unknown). From the skilled nursing facility R1 was transported to Anaheim Hills Hospital for a short stint. R1 was then discharged from Anaheim Hills and admitted to a Board and Care facility in Fullerton where R1 passed away on 01/18/2020. There is no information to support that the care provided by the facility contributed to the death of R1. As stated above R1 had been admitted to several care facilities and hospitals before ultimately passing 11 days after R1 departed the facility, thus this allegation is unsubstantiated.

On 1/21/20, a witness reported recently being at the facility and witnessing several residents in wheelchairs waiting for a meal. One resident began yelling that they had to go to the bathroom and began begging the witness and their relative for help. The witness told Staff Member #1 (S1) who was working at the front desk. S1 came over to the resident, picked them up by the arm pits, then dropped them back down into the wheelchair without providing the assistance the resident required. Interviews conducted by LPAs on 1/23/20 with 6 residents could not corroborate any rough treatment of residents by S1. Per facility documents and interviews, S1 is a receptionist. On 1/28/21, LPAs interviewed S1 who denied picking up and dropping the resident as reported and stated they do not touch residents in such circumstances, but instead call caregivers to assist. In any event, during the incident alleged by the witness, although S1 was unable to properly handle the resident or provide the proper care and supervision, it does not appear from the evidence obtained that S1 acted with malice or bad intent. Thus, the evidence obtained does not corroborate or contradict the allegation and this allegation is determined to be unsubstantiated. (Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 22-AS-20200121160538

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: 06/03/2021

NARRATIVE

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On 1/23/20, LPAs interviewed 2 residents who corroborated that the facility had a hot water outage for 3 days. An incident report dated 1/13/20 and work orders dated 1/12/20 to 1/16/20 describe a gas outage to the water heater on third floor which took approximately 3 days to repair. While the hot water outage took place, the documentation shows the outage did not affect the entire facility, the facility immediately worked to fix the identified problem, and the repairs were done quickly and completely. The 2 residents who experienced the outage did not indicate the hot water outage affected their bathing schedules. Further, 5 residents were unaffected by the outage either because they were not in the affected section of the facility or because they were given sponge baths. Because the hot water outage was localized, short-lived, repaired immediately, and did not affect resident bathing schedules, this allegation is determined to be unsubstantiated.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was left at the facility.

(Page 3)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 8

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
01/21/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200121160538

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: 86	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Marty Oh		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff did not assist resident with administration of medications.
Food service inadequate.

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Operating Manager (OM) Marty Oh and explained the reason for today’s inspection.

The investigation into allegations that Staff did not assist resident with administration of medications and food service inadequate revealed the following:

During the course of the investigation, LPAs Lydia Martinez and Ruth Martinez interviewed Administrator (AD) Hope Pak, 1 witness, 1 staff member, and 6 residents, conducted an on-site visit on 1/23/20, and obtained and reviewed the following records relating to Resident #1 (R1): hospital medical records, hospice medical records, resident file, death certificate, incident report, and work orders.

(Page 1)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 22-AS-20200121160538

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: 06/03/2021

NARRATIVE

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On 1/21/20, a witness reported that R1 had been prescribed a long list of medications, including heart/cholesterol medication, blood pressure medication, and dementia medication, for years but was told by facility staff that R1 was taken off all medications except iron supplements on 12/24/19. Per hospice medical records, the medication was stopped by the order of the hospice doctor once R1 was discharged from hospice in July 2019. The doctor’s order discharging R1 from hospice never made it to the pharmacy and the medication continued to be delivered for R1 and administered to R1 up until December 2019. Thus, the facility did assist R1 with administration of medications and this allegation is determined to be unfounded. However, the facility continued to administer medications even after they were discontinued—this will be addressed in an LIC809.

On 1/21/20, a witness reported that R1 had lost 10 pounds in a short period of time and was not eating the food provided by the facility. R1’s relative asked AD if R1 could have cottage cheese and soup, but AD would not provide these alternative requests without additional charge. LPAs interviewed AD on 1/23/20 and AD stated the facility does follow special diets for medical conditions, for example for residents with diabetes or who require low sodium. The facility has alternative foods on hand if a resident does not like what is being served, including peanut butter and jelly sandwiches, salad, fruit, chicken nuggets, and soup. However, AD stated that if a resident requests an alternative choice that the facility does not have on hand, like cottage cheese, then the resident can purchase it themselves and keep it in their room or pay an additional fee for the facility to purchase it to provide to them regularly. LPAs reviewed R1’s resident file and Physician Reports (LIC602A) dated 11/6/14 and 7/28/15 which identify special dietary requirements of “no seeds, nuts, dark greens, vit K” and “mech soft diet” respectively, but do not specifically mention cottage cheese. Applicable regulations do not require a facility to provide specific alternative food items to a resident absent a medical requirement, thus the allegation that food service is inadequate because a specific alternative food was not provided is determined to be unfounded.

The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was left at the facility.

(Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 8