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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:11:18 PM


Document Has Been Signed on 08/03/2023 12:11 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: 86DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Erik DoanTIME COMPLETED:
12:25 PM
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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-20200605173408. LPA met with Erik Doan and explained the reason for today’s inspection. Administrator (AD) Hyo Sook Kim was not present during the inspection.

During the course of the investigation, LPAs inspected the facility via tele-visit due to COVID-19 and pre-cautionary measures, interviewed AD and 2 witnesses, and obtained and reviewed copies of R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 03/03/17 and R1’s Supportive Hospice Care Medical Records dated from 05/01/20 to 06/24/20.

Per interview with Witness #1 (W1), on 06/05/20 W1 observed Resident #1 (R1) unattended in the middle of being changed after a facility staff had left to find wipes to finish cleaning R1. The facility staff was eventually found, but had only managed to find small baby wipes and could not find proper wipes for R1. Per W1, the facility did not have wipes available despite wipes having been recently delivered to the facility for use by W1 and R1. On 06/09/20, W1 again observed there were no wipes available for 1. LPA Haddad interviewed AD who corroborated that R1 should have had their own incontinence supplies, but was unable to provide an explanation as to why no wipes were available.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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


Document Has Been Signed on 08/03/2023 12:11 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
87307(a)(3)(D)

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87307 … (a) ... (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. … the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. 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 interviews, the licensee did not ensure wipes were available for R1 on two occasions, which poses an immediate health and personal rights risk to persons in care.
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Type B
08/10/2023
Section Cited
CCR87303(i)(1)

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87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. 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 interviews and documents, the licensee did not ensure R1 could reach the call button in their room, which poses a potential 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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 2 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: 08/03/2023
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W1 observed R1 on 06/05/20 and 06/09/20 and noted that R1 had no way of calling for help if needed because the call button was too far from R1’s bed for R1 to reach. R1’s Supportive Hospice Care Medical Records dated from 05/01/20 to 06/24/20 (page 181) corroborate that R1 was not able to reach the call button as hospice staff observed this was the case on 06/10/20 and in response provided an umbrella to R1 to use to reach the button. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 03/03/2017 states that R1 is not able to independently transfer to and from bed, meaning R1 could not get out of bed to reach the call button if needed. This is corroborated by R1’s Supportive Hospice Care Medical Records dated from 05/01/20 to 06/24/20 (page 167) which state that R1 requires maximal/complete assistance with ambulation and transfer. This is further corroborated by W2 who stated that the location of the call button made it very difficult, if not impossible, for R1 to reach in light of R1’s functional limitations and that R1 had no alternative methods, such as a portable call button, to call for help.

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. 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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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