306005182-5-17-2022-22-AS-MSTC-CHTDVR-20220831030734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:02:17 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
03/25/2020 and conducted by Evaluator Lydia Martinez

COMPLAINT CONTROL NUMBER: 22-AS-20200325124107

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:	0	CENSUS: 69	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Hyo (Monica) Sook Kim		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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- Food is not of quantity or quality
- Staff did not shower resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit to the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Hyo Sook (Monica) Kim and explained the purpose of the visit.

The investigation into allegation that food is not of quantity or quality revealed the following: The allegation of food is not of quantity or quality has been previously addressed in connection with Complaint Control Numbers: 22-AS-20200115103431, filed on 01/15/2020, where the allegation was Substantiated; in 22-AS-20200210155527 filed on 02/10/2020, allegation was Unsubstantiated; and, in 22-AS-20200311160613 filed on 3/11/2020 where allegation was Substantiated. Deficiencies were issued where Substantiated. Witness statements, review of Menus, and LPA’s observations, in the 3 months up to 03/25/2020, revealed that facility had 2 menus, one for meals served to Korea residents and one for non-Korean residents. Korean residents were served a balanced warm meal while non-Koreans were served a cold sandwich and not a nutritionally balanced meal.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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-20200325124107

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: 05/17/2022

NARRATIVE

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Evidence reviewed and observations made from January 2020 through March 2020, revealed the allegation to be Substantiated.

The investigation into the allegation that staff did not shower resident revealed the following: On 3/23/2020, witness reported Resident 1 (R1) received a bath 3 times a week initially after moving to facility in 10/2018. Per witness, in 12/2019, facility went under new management and became BOK Senior Hotel, and everything changed. Interview with R1 who stated it took a week just to get a shower. Review of the facility’s bathing schedule for the months of February and March 2020, R1 was to receive 2 showers per week. Per Shower sign off logs, R1 received a shower on 02/21/2020, 3/3/2020, 03/16/2020, 03/19/2020, and 03/26/2020. These logs do not show R1 was offered 2 showers a week as scheduled.

Based on the evidence gathered through interviews and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated.

Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted and a copy of this report along with citations and Appeal Rights (LIC 9058 01/16) and LIC811 Confidential Names was provided to the facility representative. Civil penalties are being assessed.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20200325124107

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: 05/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2022 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... This requirement was not met as evidenced by: LPAs’ review of menus, observations, and interviews revealed facility had 2 menus, one for meals served to Korean residents	1 2 3 4 5 6 7	The facility was closed on 02/25/2022.
	8 9 10 11 12 13 14	and one for non-Korean residents. Korean residents were served a balanced warm meal while non-Koreans were served a cold sandwich and not a nutritionally balanced meal. This poses an immediate health, safety, and/or personal rights risk to persons in care.	8 9 10 11 12 13 14	CIVIL PENALTY ASSESSED
Type A 05/18/2022 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basis Services - (f) Basic services shall at a minimum include: (4) Personal assistance and care … with those activities of daily living such as dressing, eating, bathing… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility was closed on 02/25/2022.
	8 9 10 11 12 13 14	Based on interviews and shower log reviews, the licensee did not ensure residents were offered showers they required, which poses an immediate health and personal rights risk to persons in care.	8 9 10 11 12 13 14	CIVIL PENALTY ASSESSED

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 Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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