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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:53:15 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
11/22/2019 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20191122092800
FACILITY NAME:BOK SENIOR HOTELFACILITY NUMBER:
306005182
ADMINISTRATOR:PAK, HOPEFACILITY TYPE:
740
ADDRESS:1100 E WHITTIER BLVDTELEPHONE:
(714) 529-1697
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 86DATE:
06/21/2021
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Marty OhTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
Staff failed to seek medical attention in a timely manner.
Staff failed to report an incident.
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 allegations of Resident sustained a fracture while in care, Staff failed to seek medical attention in a timely manner and Staff failed to report an incident was investigated by Community Care Licensing Investigation Branch (IB). The IB investigation consisted of interviews conducted with the facility staff, Administrator, witnesses as well as documentation review.
Based on information obtained during the IB investigation. Resident 1 (R1) resided in the assisted living unit at BOK Senior Hotel from 08/21/18 through 11/17/19. R1 was ambulatory and able to be mobile with some assistance occasionally dependent on health and general weakness. On 11/17/19 at about 12:30 PM R1 was in the dining room having lunch and stood to leave the table when R1 tripped on R1’s sandal and fell to the floor. (Page 1)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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 4
Control Number 22-AS-20191122092800
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: 06/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2021
Section Cited
CCR
87464(f)(1)
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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). "Care and supervision" means the facility assumes responsibility for...assistance with activities of daily living...personal care. This requirement was not met as evidence by:
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R1 is no longer residing at facility. Licensee agrees to create procedure for preventing falls and train care staff on procedure. Licensee will forward procedure to LPA by POC due date and proof of training within 2 weeks of POC due date
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Per CCL IB investigation, Licensee failed to provide adequate supervision for R1 resulting in R1 sustaining serious injuries. This poses an immediate health risk to residents in care.
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Type A
06/22/2021
Section Cited
CCR
87464(f)(6)
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Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs…This requirement was not met as evidenced by:
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R1 is no longer living at facility. Licensee agrees to create procedure for falls and train care staff on procedure. Licensee will forward procedure to LPA by POC due date and proof of training within 2 weeks of POC due date.
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Interviews confirmed Licensee failed to take R1 to seek medical attention for serious injury sustained from fall which poses an immediate health risk to residents 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20191122092800
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: 06/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements(a)Each licensee shall furnish to the licensing agency such reports...(1)A written report shall...(D)Any incident be submitted to the licensing agency which
threatens...safety or health of any resident. This requirement was not met as evidenced by:
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R1 is no longer living at facility. Licensee agreed that Operating Manager Marty Oh will read 87211 Reporting Requirements and provide a written statement that he has read the section and will comply with its requirements to LPA by POC due date.
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Based on interviews conducted, Licensee failed to report incident of R1 fall which poses a potential safety risk to residents 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20191122092800
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: 06/21/2021
NARRATIVE
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Staff attended to R1 and asked if R1 was ok, then placed R1 in a wheelchair and took R1 up to R1’s room where R1 stayed the rest of the day without a medical evaluation being conducted to determine if R1 needed to be seen at the hospital. Staff reported checking on R1 throughout the day and night. Caregiver, S1, came in the following morning of 11/18/2019 at 0700 hours and woke R1 up informing R1 that it was breakfast time. R1 informed S1 their inability to walk and S1 examined R1’s toes and foot which appeared swollen and bruised. S1 asked Med Tech, S2 to examine R1.
S2 could not find any incident/injury report from the previous day when R1 fell and was in a lot of pain. At about 1200 hours, S2 called Nurse Practitioner to come to the facility and check on R1. R1 was transported by ambulance to Southland Skilled Nursing Facility after 1:30 PM where R1 was provided x-ray of pelvis and bilateral hips which indicated an acute complete left femoral neck fracture present with complete displacement compatible with a Garden Classification IV fracture. X-rays were also taken of R1’s left foot and findings indicated acute to sub-acute fracture base of proximal phalanx of 4th toe. was diagnosed with a fractured hip and fractured foot. On 11/19/19 R1 was admitted to Lakewood Medical Center for a foot and hip fracture and on 11/20/19 a procedure was performed on R 1’s -Left Hip (Hemiarthroplasty). Interview of R1’s son indicated that the facility did not contact him and notify him of R1’s fall. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 03/08/2021. The civil penalty shall be assessed until the violation is corrected.
BOK Senior Hotel failed to immediately evaluate R1 after fall and prolonged any medical attention until the following day approximately 24 hours later. R1 was reportedly in excruciating pain, then at that time was transported to receive medical attention. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.
Based on review of supportive records, corroborative interviews the preponderance of evidence standard has been met; therefore, the above allegations Resident sustained a fracture while in care, Staff failed to seek medical attention in a timely manner and Staff failed to report an incident are SUBSTANTIATED. The California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099 D. A civil penalty is pending determination, per H&S Code section 1569.49(e). 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. This report, LIC 9099D, LIC421FC and appeal rights were provided to the facility representative. (Page 2)
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4