306005182-8-3-2023-22-AS-MSTC-CUD6XC-20230803211143

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:19:29 AM

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
11/24/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201124144806

FACILITY NAME:	BOK SENIOR HOTEL		FACILITY NUMBER:	306005182
ADMINISTRATOR:	AGAS, VIRGILIO		FACILITY TYPE:	740
ADDRESS:	1100 E WHITTIER BLVD		TELEPHONE:	(714) 529-1697
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	0	CENSUS: 86	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Erik Doan		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

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 Erik Doan and explained the reason for today’s inspection. Administrator (AD) Hyo Sook Kim was not present during the inspection.

The investigation into the allegation of lack of supervision resulting in resident eloping from facility 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 AD, and obtained and reviewed Resident #1’s (R1) Physician’s Reports for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 11/15/17 and 11/22/19, witness statements, and the facility’s Unusual Incident/Injury Report dated 11/23/20.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201124144806

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: 08/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2023 Section Cited CCR 87455(c)(3)(B)	1 2 3 4 5 6 7	87455 … Retention Limitations (c) No resident shall be … retained if … (3) The resident's primary need for care and supervision results from … (B) Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met. 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 documents and interviews, the licensee did not ensure R1 received proper care and supervision in the memory care unit for approximately 1 year after R1 was diagnosed with dementia resulting in R1 eloping from the facility, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sean Haddad	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201124144806

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: 08/03/2023

NARRATIVE

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Per witness statements, on 11/23/20 R1 left the assisted living section of the facility, was found by La Habra Police on the ground a mile away from the facility, and was taken to an emergency room for treatment for a fall with injury. The facility’s Unusual Incident/Injury Report dated 11/23/20 states that facility staff noticed R1 was missing from their room at around 5:30 AM, the facility received a call from the police stating R1 had been found at 5:44 AM, R1 was treated for minor cuts on their face, and R1’s family was notified and agreed to move R1 to memory care for increased care and supervision. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 11/15/17 states that R1 has mild cognitive impairment, but not dementia. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 11/22/19 states that R1 has dementia. AD confirmed to LPA that R1 never resided in the memory care unit at the facility and only resided in the assisted living section of the facility. Based on the evidence obtained in this investigation, R1 resided in the assisted living section of the facility for approximately one year after being diagnosed with dementia.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation of lack of supervision resulting in resident eloping from facility. The preponderance of evidence standard has been met; therefore, the above allegation is 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 and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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