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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 10/14/2020
Date Signed: 10/14/2020 07:24:38 PM

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:PAK, HOPEFACILITY TYPE:
740
ADDRESS:1100 E WHITTIER BLVDTELEPHONE:
(714) 529-1697
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 80DATE:
10/14/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:22 PM
MET WITH:Staff Monica Kim (Operating Manager), Hope Pak AdministratorTIME COMPLETED:
07:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sean Haddad and Ruth Martinez made an unannounced visit for the purpose of issuing citations for deficiencies observed during a Case Management visit conducted on 10/09/2020. LPAs arrived and met with Monica Kim and explained the nature of today's visit. At the time of report delivery Hope Pak joined the via Facetime.

During today's visit LPA's toured the facility, observed residents and staffing, observed food supply and spoke to resident's and staff.

On 10/09/2020, Licensing Program Manager (LPM) Marina Stanic, LPA’s Haddad and Martinez observed emergency exits in memory care blocked by large furniture and emergency exit in assisted living blocked and obscured by a large potted plant; observed mattresses on the floor, lacking bedframes, and lacking bedsprings in Rooms 118, 121, 123, and 131; observed Rooms 118, 121, 123, and 129 with 3 mattresses and/or 3 residents each in memory care; observed closet doors falling out of the railings in a number of rooms, including Rooms 118 and 131; observed the following in the sitting area outside memory care accessible to residents: 2 large sliding screen doors fallen out of railings, heavily worn and broken chair with arm missing and exposed wood, heavily worn wooden furniture with paint flaking off, and heavily worn chair with cushion material exposed; observed a hole in the wall of Room 131 behind door knob; stains, a soiled blue incontinence sheet, and a towel rack bracket with long and sharp screws attached under the sink in Room 131, fallen blind slats in Rooms 121 and 123, the door to Room 116 cracked open with exposed shards of wood and missing a doorknob, furniture scattered across Room 117 with a bed headboard unattached to bed and leaning on wall, a lamp without a lampshade, and 2 large open holes in 3rd floor hallway ceiling with exposed wiring and pipes; observed, visible and accessible to residents in memory care, bug spray in Room 131 observed approximately 40 soiled diapers under the bathroom sink in Room 121 and noted an overwhelming smell of urine and feces in Rooms 121 and 118; observed numerous resident bathrooms lacking soap, toilet paper, and towels,
(continued on LIC809-C)
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
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 10
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: 10/14/2020
NARRATIVE
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 including Rooms 131, 121, 118, 122, 123, and 366, and observed the first floor bathrooms designated for public, staff, and resident use lacking soap, paper towels, toilet seat covers, and sanitizer; observed several residents left unattended or needing help and staff not available; noted signal system not working on any of facility’s 3 floors after testing and interview with Operating Manager revealed that on that particular day reception/call desk was not staffed so no resident signals were received or answered; observed third floor memory care had been vacated and left in disarray with residents’ belongings and furniture that had not been relocated when the residents were relocated to other floors; observed Korean residents receiving appropriate and carefully chosen Korean foods, but non-Korean residents received a less appropriate and less carefully chosen foods such as a cold egg salad sandwich, canned corn, canned beans, and salad; LPAs reviewed records evidencing that for 2 weeks a cold sandwich was the non-Korean’s option for dinner. LPAs reviewed communication log which stated there was no hot water, LPA’s interviewed Operating Manager who stated there was no hot water for a week, and interview with resident in Room 225 who stated there was no hot water. LPAs interviewed Operating Manager who identified staff James Lee as Activity Director and reviewed LIC500 which identified this same staff as Housekeeping/Maintenance, meaning he is not a full-time Activity Director.

NCC letter was provided to Staff Monica Kim (Operating Manager).

Based on the observations made during visit on 10/09/2020, the following 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 as well as Appeal Rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: LPAs observed emergency exits in memory care blocked by large furniture and
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emergency exit in assisted living blocked and obscured by large potted plant. This poses an immediate health and safety risk to persons in care.
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Type A
10/15/2020
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: LPAs observed large closet doors falling partially or completely out of their railings in a number of rooms, including
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Rooms 131 and 118, rendering operation of the closet doors both difficult and hazardous. This poses an immediate health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: LPAs observed the following in the sitting area outside memory care accessible to residents: 2 large sliding
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screen doors fallen out of railings, heavily worn and broken chair with arm missing and exposed wood, heavily worn wooden furniture with paint flaking off, and heavily worn chair with cushion material exposed. This poses an immediate health, safety and/or personal rights risk to persons in care.
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Type A
10/15/2020
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: LPAs observed hole in wall of Rm 131; stains, soiled blue incontinence sheet, towel rack bracket with sharp screws under sink in Rm 131; fallen blind slats in
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Rms 121 and 123; door to Rm 116 cracked open and missing doorknob; furniture scattered across Rm 117 with a bed headboard leaned on wall; a lamp without a lampshade; and 2 large open holes in ceiling with exposed wiring and pipes. This poses an immediate health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 4 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited

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Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: … (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement was not met as evidenced by: LPAs observed, visible and accessible to residents in memory care, bug spray in Room 131. This poses an immediate health, safety and/or personal rights risk to persons in care.
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Type A
10/15/2020
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: LPAs observed approximately 40 soiled diapers under the bathroom sink in Room 121 and noted an overwhelming
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smell of urine and feces in Rooms 121 and 118. This poses an immediate health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 5 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited

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Personal Accommodations and Services: (a)(3) … 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: LPAs observed numerous resident bathrooms lacking soap, toilet paper, and towels, including Rooms 131, 121, 118,
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122, 123, and 366, and observed the first floor bathrooms designated for public, staff, and resident use lacking soap, paper towels, toilet seat covers, and sanitizer. This poses an immediate health, safety and/or personal rights risk to persons in care.
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Type A
10/15/2020
Section Cited

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Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: LPAs observed the following: Resident 1 unattended and non-responsive in Room 117; Resident 2 in
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Room 117 unattended and not wearing pants; and Resident 3 in Room 368 with 2 full urine collection bottles that had not been collected by staff. This poses an immediate health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 6 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited

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Maintenance and Operation: (i)(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: LPAs observed signal system not working on
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any of 3 floors after testing and interview with Operating Manager revealed that on that particular day reception/call desk was not staffed so no resident signals were received or answered. This poses an immediate health, safety and/or personal rights risk to persons in care.
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On today's visit, LPAs observed signal system to have been repaired and functioning properly. LPAs conducted tests to verify signal system was functioning.
Type A
10/15/2020
Section Cited

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Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: … (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water… This requirement was not met as evidenced by: LPAs reviewed communication log which stated no hot
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water, interviewed Operating Manager who stated no hot water for a week, and interviewed Resident 4 in Room 225 who stated hot water did not work. This poses an immediate health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 7 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2020
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish ... (1) A written report ... within seven days of the occurrence of ... (D) Any incident which threatens the welfare, safety or health ... of any resident. This requirement was not met as evidenced by: Based on LPAs’ observation, interview, and review of records, Facility did not report the
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triggering of fire alarm due to water leak, week-long hot water outage, bedbugs in Rm 226, and death reports dated 8/7/20 and 7/21/20 which were found in facility files but not received by CCLD. This poses a potential health, safety and/or personal rights risk to persons in care.
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Type B
10/28/2020
Section Cited

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Personal Accommodations and Services: (a)(3) … the licensee shall assure provision of: (A) A bed for each resident … Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This requirement was not met as evidenced
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by: LPAs observed mattresses on the floor, mattresses lacking bedframes, and mattresses lacking bedsprings in Room 131, 123, 121, and 118. This poses a potential health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2020
Section Cited

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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles... This requirement was not met as evidenced by: LPAs observed
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third floor had been vacated and left in disarray with residents’ belongings and furniture that had not been relocated when the residents were relocated to other floors. This poses a potential health, safety and/or personal rights risk to persons in care.
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Type B
10/28/2020
Section Cited

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General Food Service Requirements: (b) … (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement was not met as evidenced by: LPAs observed Korean American residents receiving
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appropriate, carefully chosen Korean foods, but non-Korean residents received a less appropriate food such as cold sandwich, less appetizing food means residents less likely to be well fed; records reviewed showed sandwich as dinner for 2 weeks. This poses a potential health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2020
Section Cited

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Planned Activities: (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary … The responsible employee shall have had at least one year of experience... This requirement was not met as
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evidenced by: LPAs interviewed Operating Manager who identified staff James Lee as activity director and reviewed LIC500 which identified this same staff as housekeeping and maintenance, meaning he is not a full-time activity director. This poses a potential health, safety and/or personal rights risk to persons in care.
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Type B
10/21/2020
Section Cited

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Personal Accommodations and Services: (a)(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: … (D) Not more than two residents shall sleep in a bedroom. This requirement was not met as evidenced by: LPAs observed 3 mattresses and/or 3 residents identified
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as residing in Rooms 129, 123, 121, and 118 in memory care. This poses a potential health, safety and/or personal rights 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 10 of 10