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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:45:56 PM


Document Has Been Signed on 04/15/2022 03:45 PM - It Cannot Be Edited

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 HOTELFACILITY NUMBER:
306005182
ADMINISTRATOR:HYO SOOK KIMFACILITY TYPE:
740
ADDRESS:1100 E WHITTIER BLVDTELEPHONE:
(714) 529-1697
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:0CENSUS: 65DATE:
04/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Hyo Sook KimTIME COMPLETED:
04:00 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201027085947. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection.

During the course of the investigation, LPAs inspected the facility via tele-visit due to COVID-19 and pre-cautionary measures, interviewed multiple staff and witnesses, and obtained and reviewed copies of Resident #1’s (R1) Norwalk Community Hospital Medical Records dated 11/13/2020, R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 07/09/2019, R1’s Resident Appraisal Residential Care Facilities for the Elderly (LIC 603A) dated 07/20/2019, R1’s Appraisal/Needs and Services Plan (LIC 625) dated 10/02/2020, R1’s Resident Body Check dated 09/10/2020, the facility’s Communication Log for R1 dated between 08/01/2020 and 10/26/2020, AD’s T-Mobile Cell Phone Records dated between 09/07/2020 and 12/06/2020, and the facility’s Spectrum Phone Records dated between 04/01/2020 and 12/31/2020.

Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020, the facility’s Communication Log for R1 dated between 08/01/2020 and 10/26/2020, and interviews with witnesses and facility staff, R1 tested positive for COVID-19 on 10/23/2020 and was isolated at the facility, however based on review of incident reports received at the Orange County Regional Office, the facility did not report this case of COVID-19 to LPA or the Orange County Regional Office.

Per interviews with Witness #1 (W1), R1 had a long-standing toe amputation wound which was slow to heal and home health would go to the facility about 3 times a week to treat the wound. Interviews with facility staff revealed that R1 came to the facility with the wound and received home health treatment while at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 04/15/2022
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Facility staff also stated during interviews that at some point, R1’s Veterans Affairs (VA) insurance refused to pay for home health, so the facility nurse began treating the wound. However, the facility produced no records to support this statement or nursing notes documenting care provided for R1’s wound.

Based on the interviews conducted and records reviewed during the investigation, violations are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Based on review of the facility's compliance history, which revealed the licensee was cited for the same violation 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 and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/15/2022 03:45 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports …: (2) Occurrences, such as epidemic outbreaks, … This requirement was not met as evidenced by:
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Based on documents and interviews, the facility did not report that R1 had tested positive for COVID-19, which poses an immediate health and safety risk to residents in care.
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CIVIL PENALTY ASSESSED
Type B
04/29/2022
Section Cited

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87631 Healing Wounds (a) … the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (3) ... (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by:
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Based on documents and interviews, the facility could not produce any documentation of the care provided to R1’s wound, which poses a potential health and 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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