306005182-8-3-2023-22-AS-MSTC-CUD6PL-20230803205919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:43:40 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
05/04/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200504101736

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: 86	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Erik Doan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to provide medical records to first responders
There was no qualified administrator or administrator designee on the premises to assist first responders

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 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 allegations that staff failed to provide medical records to first responders and there was no qualified administrator or administrator designee on the premises to assist first responders revealed the following: During the course of the investigation, California Department of Social Services (Department) staff inspected the facility, interviewed Resident #1 (R1), Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3), and obtained and reviewed copies of the resident roster, staff roster, staff schedules, R1’s St. Jude Medical Center Medical Records dated 05/14/20, R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 01/25/20, a La Habra Police Department Report dated 04/30/20, a facility Incident Report dated 05/01/20, the facility’s Communication Logs dated from 04/27/20 to 04/29/20, and the staff files for S3, Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7).

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)

Page: 1 of 8

Control Number 22-AS-20200504101736

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 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 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, facility staff were not able to provide R1’s basic personal or medical information to first responders necessary their evaluation of R1, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 08/10/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) ... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. .... 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 that there was a qualified administrator substitute on the premises to supervise other staff and assist first responders, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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)

Page: 2 of 8

Control Number 22-AS-20200504101736

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation into the allegations that staff failed to provide medical records to first responders and there was no qualified administrator or administrator designee on the premises to assist first responders revealed the following: Per witness statements, on 04/30/20 first responders arrived at the facility to assess R1, but the facility staff members present at the facility were all recent hires/trainees who could not assist the first responders or provide basic personal or medical information about R1. S1 and S3 admitted in interviews that the facility staff did not provide the requested information to the first responders, but claimed that the first responders prevented S3 from gathering the requested information. However, the facility’s staff schedule for 04/30/20 identifies 4 other staff working at that time who should have provided the requested information to the first responders. Per witness statements, without the requested information the first responders did not have a starting point to evaluate R1. S1 stated that there was a supervisor on duty when first responders arrived. The facility’s staff schedule for 04/30/20 identifies S3, S4, S5, S6, and S7 as the staff working at that time. However, based on review of the staff files for these 5 staff, 4 of them were hired in 2020 and the most senior staff, S7, had worked at the facility for less than 6 months. Based on their seniority, none of these staff were qualified to be the administrator designee and S7’s staff record does not document any training, education, or experience relating to being the administrator designee. In addition, based on the facility’s floor plan, any administrator designee present should have known that first responders had arrived and gone out to assist them and should have otherwise supervised the other staff to ensure the first responders received assistance, but they did not.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations that staff failed to provide medical records to first responders and there was no qualified administrator or administrator designee on the premises to assist first responders. 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 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)

Page: 3 of 8

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
05/04/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200504101736

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: 86	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Erik Doan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained repeated unexplained injuries while in care.
Staff failed to seek medical attention in a timely manor resulting in resident's hospitalization
Staff are not trained to take care of residents
Fire alarm system is defective generating false alarms

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

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)

Page: 4 of 8

Control Number 22-AS-20200504101736

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the course of the investigation, California Department of Social Services (Department) staff inspected the facility, interviewed Resident #1 (R1), Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3), and obtained and reviewed copies of the resident roster, staff roster, staff schedules, R1’s St. Jude Medical Center Medical Records dated 05/14/20, R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 01/25/20, a La Habra Police Department Report dated 04/30/20, a facility Incident Report dated 05/01/20, the facility’s Communication Logs dated from 04/27/20 to 04/29/20, and the staff files for S3, Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7).

The investigation into the allegation that R1 sustained repeated unexplained injuries while in care revealed the following: Per witness statements, on 04/30/20 R1 was observed at the facility with severe bruising to the left side of their face and a healing cut to the top of their head with a scab and R1 was taken to St. Jude Medical Center for assessment. S1 and S2 stated in interviews that they first noticed a bump on R1’s forehead on 04/27/20 and a facility Incident Report dated 05/01/20 states the facility med technician first noticed the bump on 04/26/20. Per R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 01/25/20 and interview with S1, R1 is independent and has no dementia. S1 stated in interview that R1 denied pain, falls, or abuse in connection with the bump on R1’s head and that R1 reported to facility staff that R1 just woke up with the bump one day and R1 does not know how R1 got the bump. Per interview with R1, R1 denied any abuse, falls, or pain associated with the bump or bruising to their face.

The investigation into the allegation that staff failed to seek medical attention in a timely manner resulting in R1’s hospitalization revealed the following: Per interview with S1 and review of a facility Incident Report dated 05/01/20 and the facility’s Communication Logs dated from 04/27/20 to 04/29/20, the bump on R1’s head was noticed on 04/26/20, R1’s primary care physician was notified, R1’s primary care physician recommended that facility staff monitor R1 for changes in condition, and facility staff monitored R1 for changes in condition and documented the healing of R1’s bump and bruise. S1 stated in interview that on 04/30/20 R1 was taken to St. Jude Medical Center for assessment. R1’s St. Jude Medical Center Medical Records dated 05/14/20 confirmed R1 was evaluated on 4/30/20 at the hospital and state that R1 denied having any pain or discomfort, R1 was not diagnosed with any injuries, R1 refused all treatment and diagnostic testing and stated they just wanted to go home because they felt fine and had no pain, and R1 was discharged back to the facility.

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)

Page: 5 of 8

Control Number 22-AS-20200504101736

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation into the allegation that staff are not trained to take care of residents revealed the following: Per facility Incident Report dated 05/01/20, the facility’s Communication Logs dated from 04/27/20 to 04/29/20, and interview with S1, when R1’s bump and bruise were noticed by facility staff on 04/26/20, facility staff assessed R1, reported the injuries to R1’s primary care physician, followed the orders given by R1’s primary care physician, monitored R1 for changes in condition, and documented the healing of R1’s bump and bruise. After returning to the facility from St. Jude Medical Center, R1 stated in interview that they enjoy living in the facility, the facility staff take good care of R1 and feed R1 well, and R1 has no complaints about the facility. The facility’s staff schedule for 04/30/20 states that S3, S4, S5, S6, and S7 were scheduled to work on 04/30/20 during the PM shift. LPA reviewed staff records documenting that S3, S4, S5, S6, and S7 received all required trainings.

The investigation into the allegation that the fire alarm system is defective generating false alarms revealed the following: This allegation was previously addressed in connection with Complaint Control No. 22-AS-20200221062101 where the allegation was substantiated, a deficiency was issued on 08/13/21, and the facility took measures to repair and inspect the fire alarm system. Per witness statements, in the 12 months preceding 05/04/20 the facility generated almost 50 false fire alarms. In addition, LPAs inspected the facility on 05/12/20 and noted the facility’s Communication Logs included an entry for a false alarm incident on 04/06/20, but the entry did not state what triggered the false alarm. Based on the evidence gathered during this investigation, it is unclear whether the fire alarm system generated false alarms to an extent not already addressed in connection with Complaint Control No. 22-AS-20200221062101.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that a resident sustained repeated unexplained injuries while in care, staff failed to seek medical attention in a timely manner resulting in a resident's hospitalization, staff are not trained to take care of residents, and the fire alarm system is defective generating false alarms 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 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)

Page: 6 of 8

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
05/04/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200504101736

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: 86	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Erik Doan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to report incidents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 that staff failed to report incidents revealed the following: During the course of the investigation, California Department of Social Services (Department) staff inspected the facility, interviewed Resident #1 (R1), Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3), and obtained and reviewed copies of the resident roster, staff roster, staff schedules, R1’s St. Jude Medical Center Medical Records dated 05/14/20, R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) dated 01/25/20, a La Habra Police Department Report dated 04/30/20, a facility Incident Report dated 05/01/20, the facility’s Communication Logs dated from 04/27/20 to 04/29/20, and the staff files for S3, Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7).

Unfounded

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)

Page: 7 of 8

Control Number 22-AS-20200504101736

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation into the allegation that staff failed to report incidents revealed the following: A facility Incident Report dated 05/01/20 states that the bump on R1’s head was reported to R1’s primary care physician. Based on review of Department records, the facility Incident Report dated 05/01/20 was received by the Department on 05/04/20 and therefore the incident was reported to the Department.

The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report 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)

Page: 8 of 8