306005182-7-26-2020-22-AS-MSTC-BSGURE-20200814154837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 07/24/2020
Date Signed: 07/26/2020 09:43:39 AM

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
02/06/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200206113644

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: 93	DATE:	07/24/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hope Pak		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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* Resident was not provided breakfast on time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez contacted the facility via telephone to deliver findings on the above allegation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Hope Pak.

During the course of the investigation, LPAs Lydia Martinez and James August toured the facility, interviewed residents, staff and Resident 1’s (R1) family, as well as reviewed and obtained pertinent documentation such as R1’s meal log from 12/9/2019 to 01/02/2020, and staff timecard for week of 2/1/2020 to 2/15/2020.

Regarding allegation that Resident was not provided breakfast on time the investigation revealed the following: Interview with witness reported she arrived to the facility at 9:45am and shortly after observed two staff entering R1’s room to give R1 food.

(see LIC9099C)

Unsubstantiated

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: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200206113644

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: 07/24/2020

NARRATIVE

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Witness reported when she asked the staff why they were feeding R1 so late, staff replied that breakfast had arrived late. Interview with one of the staff members, staff stated she is who feeds R1 daily but sometimes she gets help from other staff. Staff stated they have been given instructions from R1’s daughter not to wake R1 up to eat and/or to not give R1 food when she is half asleep. Staff stated this was the case on that day. R1 was asleep therefore they waited until R1 woke up to feed her. This was corroborated by R1’s daughter when interviewed by LPA. R1’s daughter stated she has told staff not to wake R1 up and to wait until R1 wakes up on her own. R1’s daughter states she is aware R1 sometimes eats late because she visits every day and brings R1 food and staff notify her that R1 ate late because R1 woke up late.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

LIC9099 (FAS) - (06/04)

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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
02/06/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200206113644

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:	DATE:	07/24/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hope Pak		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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* Facility administrator/designated substitute was not present at the facility

INVESTIGATION FINDINGS:

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Regarding allegation that facility Administrator/designated substitute was not present at the facility, the investigation revealed the following: Interview with witness reported she asked to speak to the Administrator and was told Administrator was not in the facility. Witness stated MedTech attempted to contact another Administrator but was not available either. Witness stated she did not ask who was in charge but confirmed Michelle Song, Receptionist was present. Review of documents confirm Michelle Song is named as an Administrator Designee.

Therefore, allegation is deemed Unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Hope Pak via telephone and a copy of this report was provided to Executive Director via email and an electronic email read receipt confirms receiving these documents. Administrator agrees to sign and return signed document.

Unfounded

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: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

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

LIC9099 (FAS) - (06/04)

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