306005182-7-22-2021-22-AS-MSTC-CHTCQ8-20220831020732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:47:09 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
07/19/2021 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210719124814

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: 84	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	02:22 PM
MET WITH:	Marty Oh		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not administer oxygen to resident as ordered.
Facility staff is not safeguarding resident's belongings.

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegations. LPA met with Operating Manager (OM) Marty Oh, discussed the purpose of the inspection, explained the allegations, and conducted the investigation.

The investigation into allegations that Facility did not administer oxygen to resident as ordered and Facility staff is not safeguarding resident's belongings revealed the following:

During the course of the investigation, LPA reviewed witness reports, interviewed OM, and reviewed facility files. Witnesses reported that Resident #1 (R1), who is on oxygen, was seen not on oxygen on 07/18/21 and 07/19/21, with the oxygen concentrator and cannula having been removed from R1’s room. It was further reported that on 07/19/21, R1’s oxygen saturation was 92% on room air, R1 was not in distress, and R1 was not having dyspnea. (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: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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-20210719124814

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: 07/22/2021

NARRATIVE

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LPA’s interview with OM corroborated the witness reports and confirmed the oxygen concentrator and cannula were removed from R1’s room and used for another resident because that other resident was having an emergency and facility staff could not find the facility’s extra oxygen machinery. LPA’s review of medical records revealed that R1 was prescribed the oxygen and had doctor’s orders for the oxygen to be administered, thus the facility did not administer the oxygen to R1 as ordered and this allegation is substantiated. In addition, the oxygen concentrator and cannula were assigned for the use of R1 and R1 alone, thus by removing them from R1’s room for use on another resident, the facility staff did not safeguard R1’s belongings and this allegation is substantiated.

During today’s inspection, LPA confirmed the oxygen concentrator and cannula have been returned to R1’s room and conducted a health and safety check on R1 and found no health and safety issues.

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. 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: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210719124814

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: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/23/2021 Section Cited CCR 87611(e)	1 2 3 4 5 6 7	87611 General Requirements for Allowable Health Conditions (e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	On 7/20/21, Operating Manager found facility's extra oxygen machinery, placed it in the med tech room, and trained med techs to never use another resident's oxygen machinery, that the extra machinery is in the med tech room, if it is missing to notify Operating Manager, and to make sure to use new tubing for each resident.
	8 9 10 11 12 13 14	Interviews and records revealed the licensee removed R1’s oxygen concentrator and cannula from R1’s room which prevented administration of oxygen to R1 per doctor’s order, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	During today's inspection, LPA confirmed the extra oxygen machinery is in the med tech room. Licensee agrees to submit proof of the above training within 7 days of POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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