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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:27:28 PM

Substantiated


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
10/27/2020 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201027085947
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:0CENSUS: 65DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Hyo Sook KimTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident was left unattended on the floor
Facility staff failed to meet the resident's 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 allegation. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection.
The investigation into the allegations that a resident was left unattended on the floor and facility staff failed to meet a resident's needs revealed the following: 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.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The investigation into the allegation that R1 was left unattended on the floor revealed the following: Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 1045), on 10/26/2020 Emergency Medical Technicians (EMTs) went to the facility to take R1 to Norwalk Community Hospital and found R1 naked on the floor with a blanket over them. The EMTs also stated they encountered a facility staff member at the facility who stated they were trying to pick R1 up to take R1 to the bathroom, but did not have any help. The facility’s Communication Log for R1 (entry date 10/23/2020) states that R1 tested positive for COVID-19 on 10/23/2020 while at the Veterans Affairs (VA) Hospital in Long Beach and that R1 was discharged back to the facility that same day on 10/23/2020. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 301) corroborate that R1 tested positive for COVID-19 on 10/23/2020 while at the VA Hospital in Long Beach. The facility’s Communication Log for R1 (entry date 10/23/2020) states that, due to R1’s COVID-19 diagnosis, R1 was isolated on the 3rd floor. The facility’s Communication Log for R1 (entry dates 10/24/2020, 10/25/2020, and 10/26/2020) states that during R1’s isolation, R1 kept “moving around and trying to go out of [R1’s] room” and “it is very difficult to keep [R1] in [their] room,” R1 kept “moving on the floor” and “trying to take off [their] clothes,” “[R1] is not cooperative,” “[R1] is not staying in [their] bed,” and “it is very difficult to take care of [R1].” Per interviews with facility staff, when R1 was isolated on the 3rd floor, facility staff checked on R1 every hour and while in isolation, R1 would often move around their room, move from the bed to the floor, take their clothes off, and place a blanket over themselves. This is how R1 was found by the EMTs on 10/26/2020. Per the facility’s Communication Log for R1 (entry date 10/26/2020), it was the facility staff who called the EMTs to take R1 to the hospital on 10/26/2020, but the EMTs did not coordinate with facility staff, did not ask any questions about R1, and did not obtain or transmit to the receiving hospital information about R1 or why R1 was being sent out to the hospital. While facility staff stated during interviews that they checked on R1 every hour while R1 was in isolation, apart from daily checks documented on the facility’s Communication Log for R1, the facility could not produce any documentation regarding these hourly checks which would show that R1 received proper care and supervision during R1’s isolation. While the facility was aware that R1 was taking their clothes off and moving onto the floor while in isolation, the facility did not revaluate R1 for a change of condition or provide additional care and supervision to address this behavior.
The investigation into the allegation that facility staff failed to meet R1's needs revealed the following: Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 271), as of 10/26/2020 R1’s medical history included “[an] old stroke, dementia, gastroesophageal reflux disease, benign prostatic hypertrophy, anemia, peripheral vascular disease, status post right 5th toe amputation and left foot transmetatarsal amputation, history of recent scabies for which [R1] is being treated with ivermectin.”
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
LIC9099 (FAS) - (06/04)
Page: 2 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 301) also state that R1 tested positive for COVID-19 on 10/23/2020 while at the VA Hospital in Long Beach. During the course of the investigation, LPA obtained conflicting information from the facility staff and their phone logs and Witness #1 (W1) and W1’s phone logs. The facility staff stated they reached out via telephone, however there was no documentation of other methods of communication attempted such as text messages, email, or certified letter when W1 allegedly did not respond to telephone calls.
The facility’s Communication Log for R1 dated between 08/01/2020 and 10/26/2020 states that on 08/01/2020 R1’s medications were not delivered from the VA Pharmacy, facility staff tried to call W1 to help coordinate with the pharmacy, W1 did not answer, facility staff left a message, but W1 did not call back. The facility’s Communication Log for R1 (entry date 08/04/2020) states that the facility did eventually receive the medications on 08/04/2020. The facility’s Communication Log for R1 (entry date 08/14/2020) states that facility staff tried to call W1 to discuss rent, W1 did not answer, and facility staff left a message. The facility’s Communication Log for R1 (entry date 09/01/2020) states that R1’s medications were not delivered from the VA Pharmacy, facility staff tried to call W1 to help coordinate with the pharmacy, W1 did not answer, facility staff left a message, but W1 did not call back. The facility’s Communication Log for R1 (entry date 09/05/2020) states that the facility did eventually receive the medications on 09/05/2020. R1’s Resident Body Check dated 09/10/2020 states that R1 has a rash and a facility staff member called R1’s doctor who indicated they were going to conduct a video call to look at the rash, but the doctor never called the staff member back, and the staff member tried to call W1 for help but did not “find the help either.” The facility’s Communication Log for R1 (entry date 09/14/2020) states that facility staff tried to call W1 to discuss rent and R1’s “status” and W1 did not answer. The facility’s Communication Log for R1 (entry date 09/15/2020) states that facility staff tried to call W1 again, W1 did not answer, facility staff left a message, but W1 did not call back. The facility’s Communication Log for R1 (entry dates 09/16/2020, 09/18/2020, 09/21/2020, and 09/24/2020) describes four (4) calls to W1, which W1 did not answer, by facility staff to discuss obtaining a doctor’s appointment for a rash observed on R1. The facility’s Communication Log for R1 (entry date 09/30/2020) states that facility staff called W1 to discuss R1’s condition and request that W1 make an appointment for R1 at the VA Hospital, W1 answered the phone and told facility staff W1 would call them back, W1 did not call back, facility staff tried to call W1 again but had to leave a message, and W1 did not call back. The facility’s Communication Log for R1 (entry date 10/01/2020) states that facility staff called W1 to request that W1 make an appointment for R1 at the VA Hospital, W1 did not answer the phone, facility staff made the appointment for 10/06/2020 themselves, facility staff called W1 again to request that W1 take R1 to the VA Hospital for the appointment, and W1 did not answer the phone.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The facility’s Communication Log for R1 (entry date 10/02/2020) states that facility staff called W1 to remind W1 to take R1 to the hospital for R1’s doctor’s appointment, but W1 did not answer. The facility’s Communication Log for R1 (entry date 10/05/2020) states that facility staff called W1 about R1’s doctor’s appointment, W1 did not answer, and facility staff decided to take R1 to the VA Hospital themselves for the appointment. The facility’s Communication Log for R1 (entry date 10/06/2020) states that facility staff took R1 to the VA Hospital for R1’s doctor’s appointment at 9:30 AM, returned with R1 that same day at 1:30 PM, did not bring R1’s medications with them, and called the VA Pharmacy to send R1’s medications. Interviews with facility staff clarified that these medications were for scabies because R1 was diagnosed with scabies at this doctor’s appointment. The facility’s Communication Log for R1 (entry date 10/13/2020) states that the medications were eventually received on 10/13/2020. On 10/09/2020, LPAs inspected the facility and conducted in-person health and safety checks on multiple residents, including R1. LPAs did not note any health and safety issues with respect to R1. LPAs interviewed R1 in their room who stated they were doing “OK” and that the food at the facility is “OK”. As will be further discussed below, per interviews with W1, W1 denies receiving any of the calls described above, except for a single call requesting that W1 assist with obtaining R1’s medication. However, based on the interviews conducted and records reviewed, apart from R1’s history of medical issues, as of 10/13/2020 R1 had developed scabies, been seen at the VA Hospital on 10/06/2020, was not hospitalized or referred to a higher level of care by R1’s doctor, and had been released back to the facility.
The facility’s Communication Log for R1 (entry date 10/18/2020) states that facility staff called W1 twice, W1 did not answer, R1 did not feel good and felt dizzy, and facility staff tried to speak with R1’s doctor, but had difficulty reaching the doctor as well. The facility’s Communication Log for R1 (entry date 10/19/2020) states that R1 is “very weak this morning from not eating for 2 days” and that facility staff called W1, W1 did not answer, and facility staff left a message. The facility’s Communication Log for R1 (entry date 10/20/2020) states that R1 was not getting better, facility staff called W1 twice, W1 did not answer, R1 agreed to go to the hospital, facility staff called an ambulance and R1 was taken to the VA Hospital on 10/20/2020, and facility staff left W1 a message. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 618) state that R1 was “hospitalized 10/20-10/23 at VA Long Beach for left LE cellulitis, where [R1] was treated for scabies, discharged on combination of Augmentin doxycycline ivermectin, permethrin cream and discharge to” the facility. The facility’s Communication Log for R1 (entry date 10/20/2020) states that a VA Hospital dietician called the facility on 10/20/2020, stated that R1 had lost “a lot of weight” and that they are prescribing food supplements for R1, but did not provide specifics as to how many cans of supplement R1 should eat.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The facility produced no documents demonstrating facility staff followed up with the dietician to obtain instructions regarding specific caloric intake for R1, to obtain an order for food supplements, or to obtain an order for a special diet. Also, the facility produced no documents demonstrating it tracked R1’s weight at any time during R1’s stay at the facility. In addition, the facility was issued a deficiency by LPAs on 10/14/2020 because the menu did not consist of an appropriate variety of foods after it was observed that the dinner option for two (2) weeks) was a sandwich.

The facility’s Communication Log for R1 (entry date 10/21/2020) states that facility staff called W1, W1 answered, W1 blamed the facility for not notifying them before R1 went to the hospital, and facility staff told W1 that they had tried to call W1 many times but their calls were never answered. The facility’s Communication Log for R1 (entry date 10/23/2020) states that the VA Hospital called and stated that R1 had tested positive for COVID-19 and that R1 would not be returning to the facility. The same entry states that the VA Hospital called again and stated that they could not find anywhere to place R1 so R1 has to come back to the facility, that R1 was discharged and came back to the facility on 10/23/2020, that R1 was isolated at the facility due to COVID-19, that R1 was still “very weak,” and that facility staff called W1 to report that R1 had returned but W1 did not answer. R1’s hospitalization from 10/20/2020 to 10/23/2020 at the VA Hospital is corroborated by R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 618) and interviews with W1 and facility staff. The facility did not report R1’s positive COVID-19 test result to Community Care Licensing. In addition, on 02/16/2021 LPAs inspected the facility and learned that the facility was not conducting regular COVID-19 testing and that in the year 2020, the facility had conducted mass COVID-19 testing only once on 11/18/2020. During interviews, W1 stated that in Mid-October 2020 W1 received a call from VA Hospital Long Beach stating that R1 was hospitalized there, R1 was bradycardic, R1’s organs were failing, R1 was not doing well, and R1 had scabies, but W1 stated that facility staff never advised W1 of this hospitalization. Based on the interviews conducted and records reviewed, as of 10/23/2020, R1 had been hospitalized at VA Hospital Long beach, tested positive for COVID-19 on 10/23/2020, was not referred to a higher level of care by R1’s doctor, and had been released back to the facility.

The facility’s Communication Log for R1 (entry date 10/24/2020) states that during isolation, R1 kept moving around and trying to leave R1’s room and facility staff applied R1’s topical medication for scabies. The facility’s Communication Log for R1 (entry date 10/25/2020) states that R1 did not eat breakfast, but did eat lunch with one can of food supplement, R1 kept taking their clothes off and moving to the floor of their room, and facility staff applied R1’s topical medication for scabies and changed R1’s clothes and sheets.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The facility’s Communication Log for R1 (entry date 10/26/2020) states that R1 was not cooperating with isolation, R1 was not staying in their bed, facility staff found it difficult to take care of R1, and facility staff called W1 to discuss R1’s condition, but the call was not answered. The facility’s Communication Log for R1 (entry date 10/26/2020, continued) states that R1 agreed to go to Norwalk Community Hospital to take another COVID-19 test, the facility called an ambulance to take R1 there at 10:00 AM, the ambulance first said they would not take R1 because they do not accept VA insurance, but an ambulance eventually came and took R1 to Norwalk Community Hospital at 5:00 PM and facility staff notified W1 via text message. The same entry states that the Emergency Medical Technicians (EMTs) did not coordinate with facility staff, did not ask any questions about R1, and did not obtain or transmit to the receiving hospital information about R1 and why R1 was being sent out to the hospital. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 272) state that, in addition to a COVID-19 diagnosis, R1 was admitted to Norwalk Community Hospital on 10/26/2020 with the following impression: “Sepsis with shock, sepsis present on admission, sinus bradycardia, hypothermia, rule out hypothyroidism, severe peripheral vascular disease, status post left foot transmetatarsal amputation, infected left foot plantar ulcer, old cerebrovascular accident with right hemiparesis, multiinfarct dementia, severe protein-calorie malnutrition, cachexia, altered mental status from toxic metabolic encephalopathy, history of gastroesophageal reflux disease, duodenal ulcer disease, benign prostatic hypertrophy, anemia, acute kidney injury, prerenal azotemia, dehydration, history of scabies currently being treated.” Per interviews with W1, W1 was only notified the next day that R1 had been admitted to Norwalk Community Hospital and that W1 was told by Norwalk Community Hospital staff that R1 was malnourished, had organ failure, and was bradycardic. W1 also stated in interviews that Norwalk Community Hospital did not allow W1 to see R1 due to COVID-19 restrictions.
Per interviews with W1, after being treated at Norwalk Community Hospital, R1 was released to Norwalk Meadows, a skilled nursing facility, but Norwalk Meadows made W1 wait fourteen (14) days before seeing R1 due to COVID-19 restrictions and R1 passed away on 11/30/2020 at Norwalk Meadows before those fourteen (14) days elapsed. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 235) state that R1 was discharged to Alvarado Care Center, a skilled nursing facility, on 11/12/2020 at 8:35 PM, with admitting diagnoses listed as altered mental status, hypothermia, COVID-19, volume depletion, anemia, and scabies and discharge diagnoses listed as altered mental status, volume depletion, anemia, and scabies. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (pages 11-13) state that, although R1 tested negative for COVID-19 at Norwalk Community Hospital prior to transfer to Alvarado Care Center, Alvarado Care Center refused to accept R1 because R1 once tested positive and Alvarado Care Center has a COVID-19 free 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
LIC9099 (FAS) - (06/04)
Page: 6 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (pages 11-13), R1 was returned to the Norwalk Community Hospital’s Emergency Room via ambulance from Alvarado Care Center on 11/13/2020 at 3:05 AM for another COVID-19 test “to make sure [R1] is truly Covid negative” and was readmitted to Norwalk Community Hospital (page 30) on 11/13/2020 at 1:35 PM with admitting diagnoses listed as elevated brain natriuretic peptide (BNP), anemia, prerenal azotemia, hyponatremia, and scabies. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 109) state that on 11/13/2020 at 6:48 AM, Norwalk Community Hospital staff were advised by Alvarado Care Center staff that Alvarado Care Center cannot accept R1 because R1 has scabies. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 111) state that on 11/13/2020 Norwalk Meadows staff stated that Norwalk Meadows had postponed taking R1 the prior day “as they wanted one more day to fulfill their 10 day requirement of being Covid negative and symptom free as they did not have an isolation room,” but that Norwalk Meadows could now take R1. Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 24), R1 was discharged via ambulance to Norwalk Meadows on 11/13/2020 at 10:03 PM.
Per interviews with W1, W1 denies receiving any of the calls described in the facility’s Communication Log for R1 dated between 08/01/2020 and 10/26/2020, except for a single call requesting that W1 assist with calling R1’s doctor to obtain medication. Interviews with multiple facility staff corroborated the number and intent of the calls described in Communication Log for R1 dated between 08/01/2020 and 10/26/2020. On 04/01/2022, LPA requested phone records from W1 and the facility. Per interviews with W1, W1 was unable to produce phone records for W1’s phone number at issue for the relevant time period (prior to 10/26/2020) because too much time had elapsed. The facility produced the facility’s Spectrum Phone Records dated between 04/01/2020 and 12/31/2020. LPA reviewed these phone records and noted calls placed from the facility to W1 on 05/20/2020 (two (2) calls), 05/25/2020, and 10/01/2020. However, these phone records do not document phone calls received by the facility and it is unclear if these phone records document attempted calls. The facility did, however, produce the phone records of AD who stated during interviews they used their personal cell phone to call W1 at various points. LPA reviewed AD’s T-Mobile Cell Phone Records dated between 09/07/2020 and 12/06/2020 and noted calls placed between AD and W1 on 10/23/2020, 10/27/2020, and 3 additional dates thereafter. Per interviews with W1, W1 was not able to see R1 at the facility after 03/12/2020 due to the facility’s COVID-19 visitation restrictions. W1 also stated that on multiple occasions W1 called the facility and asked to speak to R1 over the phone, that facility staff advised W1 they would have R1 call W1 on the facility’s phone, but that W1 never received any calls from R1. On 11/30/2020, LPAs conducted a COVID-19 Welfare Call with facility staff via telephone. During the call, the facility administrator at the time stated that the facility is not allowing visitors, but would “accommodate outside” if needed.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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Facility staff interviewed stated that R1 used to come to the front desk and would use the phone to call W1, but W1 would not answer and W1 did not visit R1 frequently. R1’s Resident Appraisal Residential Care Facilities for the Elderly (LIC 603A) dated 07/20/2019 states that R1 “likes to be with people” and “likes to visit front office.” R1’s Appraisal/Needs and Services Plan (LIC 625) dated 10/02/2020 states that R1 enjoys socializing with facility staff, that R1’s family does not answer or return calls, and that R1 has VA insurance and R1’s VA physician does not answer calls. Based on the interviews conducted and records reviewed, the information obtained regarding communication and visitation remains conflicting.

Per interviews with W1, W1 stated that on 03/12/2020 R1 weighed 180 to 190 pounds, but W1 was not able to produce records on this point The facility was not able to produce records of R1’s weight at any time during R1’s stay at the facility. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 07/09/2019 was completed by Dr. Lutfi A. Sayyur, but the section for R1’s weight was left blank. Per interviews with facility staff, R1 did not eat very well and had lost weight, so the facility sent R1 to the hospital as per their protocol. Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 162), upon admission on 10/26/2020 R1 weighed 110 pounds and (page 16) on the day of discharge on 11/13/2020 R1 weighed 120 pounds. It is clear that R1 did lose weight, but the facility did not document how much weight R1 lost and over what length of time. However, on 10/18/2020 facility staff noted that R1 did not feel good and felt dizzy and by 10/19/2020 had not eaten for two (2) days, but the facility did not obtain medical attention for R1 until 10/20/2020. Then, after being advised on 10/20/2020 that R1 had lost weight and would need food supplements, facility staff did not follow up to ensure R1’s dietary needs were being met despite the facility having been cited on 10/14/2020 for dietary issues. By delaying obtaining medical care for R1 after noting R1’s symptoms and not following up with R1’s medical team to ensure R1’s dietary needs were being met, the facility failed to meet R1's needs and this allegation is substantiated.

During the course of the investigation, the Department 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 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
LIC9099 (FAS) - (06/04)
Page: 8 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by:
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The facility was closed on 02/25/2022.
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Based on documents and interviews, while facility staff documented that R1 was difficult to care for and had changed their behavior, the facility did not reevaluate R1 for a change of condition to adequately care for the noted behavior, which poses an immediate health and safety risk to persons in care.
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CIVIL PENALTY ASSESSED
Type A
04/16/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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The facility was closed on 02/25/2022.
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Based on documents and interviews, facility staff noted R1 did not feel good and felt dizzy on 10/18/20 and had not eaten for 2 days on 10/19/20, but did not obtain medical attention for R1 until 10/20/20, which poses an immediate health and safety risk to persons 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
LIC9099 (FAS) - (06/04)
Page: 9 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87468.2(a)(5)
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87468.2 … Personal Rights … (a) … residents … shall have all of the following personal rights: (5) To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement was not met as evidenced by: Based on documents and interviews, facility staff were advised on 10/20/20 that
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The facility was closed on 02/25/2022.
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R1 had lost “a lot of weight” and would need food supplements, but did not follow up to obtain specific instructions or orders for the food supplements or a special diet to ensure R1’s nutritional needs were met, which poses an immediate health and personal rights risk to persons 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
LIC9099 (FAS) - (06/04)
Page: 10 of 13
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
10/27/2020 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201027085947

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:0CENSUS: 65DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Hyo Sook KimTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident developed pressure injury while in care
Resident has scabies
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 Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection.
The investigation into the allegations that a resident developed a pressure injury while in care and a resident has scabies revealed the following: 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.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 11 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The investigation into the allegation that R1 developed a pressure injury while in care revealed the following: 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. Facility staff also stated during interviews that at some point, R1’s 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. Per interviews with facility staff, the wound was always large and did not get worse while R1 was at the facility. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 07/09/2019 states that R1 came to the facility with a diagnosis of Left Foot Osteomyelitis. Per R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 155), on 10/26/2020 R1 was assessed to have an open wound on the left foot after a toe amputation and (page 271) R1 had a history of amputation, peripheral vascular disease, gangrene, and a recent “recurrent left foot plantar ulcer and also ulcer over the left transmetatarsal amputation stump site.” R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 271) note that R1 was being treated with wound care and oral antibiotics at the facility. While there is no documentation regarding the status of the wound and the care provided by the facility nurse, the interviews conducted indicate that R1 developed the wound prior to residing at the facility.

The investigation into the allegation that R1 has scabies revealed the following: Per interviews with W1, when W1 saw R1 at the hospital, R1 had scabies all over their body. R1’s Resident Body Check dated 09/10/2020 states that R1 has a rash and a facility staff member called R1’s doctor who indicated they were going to conduct a video call to look at the rash, but the doctor never called the staff member back, and the staff member tried to call W1 for help but did not “find the help either.” The facility’s Communication Log for R1 (entry dates 09/16/2020, 09/18/2020, 09/21/2020, 09/24/2020, 09/30/2020, 10/01/2020, 10/02/2020, and 10/05/2020) details ten (10) phone calls placed by facility staff to W1 requesting help to secure a doctor’s appointment at the Veterans Affairs (VA) Hospital for R1’s rash. These entries state that nine (9) of the calls were not answered by W1, facility staff left one (1) voicemail for W1, and one (1) call was answered by W1 on 09/30/2020. The entry dated 09/30/2020 states that facility staff told W1 about R1’s condition and requested that W1 make an appointment for R1 at the VA Hospital, but W1 told facility staff that W1 would call them back but did not call back.
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
LIC9099 (FAS) - (06/04)
Page: 12 of 13
Control Number 22-AS-20201027085947
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: 04/15/2022
NARRATIVE
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The facility’s Communication Log for R1 (entry dates 09/16/2020, 09/18/2020, 09/21/2020, 09/24/2020, 09/30/2020, 10/01/2020, 10/02/2020, and 10/05/2020) describes that facility staff applied lotion to R1 while attempting to schedule the doctor’s appointment for R1’s rash and noted the rash did get better, but R1 still needed to see a doctor. The entry dated 10/01/2020 states that, after unsuccessfully trying to coordinate with W1, facility staff made an appointment at the VA Hospital for 10/06/2020 for R1. The entries dated 10/01/2020, 10/02/2020, and 10/05/2020 detail three (3) phone calls placed by facility staff to W1 requesting that W1 take R1 to the hospital for this doctor’s appointment, but W1 did not answer. The entry dated 10/05/2020 states that, after unsuccessfully trying to coordinate with W1, facility staff decided to take R1 to the VA Hospital for the appointment themselves. The entry dated 10/06/2020 states that facility staff took R1 to the VA Hospital at 9:30 AM and returned with R1 that same day at 1:30 PM. Facility staff corroborated the communication log during interviews. Per interviews with W1, W1 denies receiving any of these calls described on the facility’s Communication Log for R1 dated between 08/01/2020 and 10/26/2020. Facility staff interviewed stated that R1 was diagnosed with scabies at the VA Hospital on 10/06/2020 and returned with prescriptions for medications (lotion and pills) which facility staff regularly gave to R1 after the facility received them from the VA Pharmacy. The facility did not produce medication administration records for the lotion and pills, but the facility’s Communication Log for R1 (entry dates 10/24/2020 and 10/25/2020) describe two instances of lotion application. R1’s Norwalk Community Hospital Medical Records dated 11/13/2020 (page 301) state that R1 also received treatment for scabies at the VA Hospital between 10/20/2020 and 10/23/2020 and was discharged back to the facility with medications and (pages 158-159) that R1 also received treatment for scabies at Norwalk Community Hospital after being admitted on 10/26/2020. However, while the facility waiting for instructions from W1 delayed treatment, the interviews conducted and records reviewed document the facility’s efforts to diagnose and treat R1’s scabies.

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 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
LIC9099 (FAS) - (06/04)
Page: 13 of 13