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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005182
Report Date: 10/08/2020
Date Signed: 10/16/2020 01:35:06 PM



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
12/05/2019 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20191205134847
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: 88DATE:
10/08/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Hope PakTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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* Residents sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lydia Martinez contacted the facility via telephone to deliver findings on the above allegations via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Administrator Hope Pak. The complaint was investigated by Community Care Licensing Investigations Branch (IB).

During the investigation, interviews were conducted with facility Administrator, staff and witnesses. Additionally, copies of St. Jude Hospital Medical records dated 11/30/19 for Resident 1 (R1), Supportive Hospice Care Medical Records from 09/21/19 to 01/29/20 for Resident 2 (R2), and Death Certificate for (R2) dated 01/31/20, were obtained and reviewed.

The investigation revealed the following: (see LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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 5
Control Number 22-AS-20191205134847
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: 10/08/2020
NARRATIVE
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R1 is an 87-year-old diagnosed with Dementia residing at the facility since 01/13/16. R1 was ambulatory, however required the assistance of a walker and was evaluated to be a fall risk. On 11/30/19, R1 was transported to St. Jude Hospital for a fall that occurred in the dining area at about 2:30 p.m. The Administrator, Hope Pak stated that R1 stood up and fell. She also stated that R1 was evaluated by staff and R1 had no pain or injury, however when R1 started walking with a limp, they were referred to St. Jude Hospital. R1 was evaluated by the attending physician who reported that there was no fracture or any apparent injury. R1 returned to the facility the same day. On 12/01/19, Staff 1 (S1) noticed a dark blue bruise on R1’s chin, mouth and right eye. S1 stated that an ice pack was provided but R1 refused to keep it on the chin. No additional medical attention was provided, and no written injury/incident report document was completed. The facility had no report of any falls or injury noted for R1 by overnight shift or morning shift. R1 was not sent to the hospital for further medical evaluation. Due to the lack of information from staff, the infrequency of resident checks, failing to document and report injury and not providing medical attention to an un-witnessed injury to the head provides enough information to support the allegation of Neglect/Lack of Care and Supervision.

Resident 2 (R2), a 94-year-old who resided at the facility since 05/24/14 had a history of cardiac problems and was admitted to hospice services on 09/20/19. R2 was very frail and weak, continuously losing weight due to poor appetite. Per Physician Report dated 02/03/17, R2’s weight was 144 pounds. Hospice notes dated 09/21/19 registered R2’s weight at 121 pounds. On 12/17/19, Hospice notes document R2’s weight loss to be 10% due to inadequate food and water intake. Documentation notes that R2 had been losing balance and falling due to weakness. On 12/17/19, Hospice noted skin tears located on leg-lower left front and left thigh. On 01/13/20, Hospice again documented R2 had two skin tears to lower extremities and R2 presented with increased confusion. R2’s daughter in-law stated the family was never notified of R2’s falls and the reason they knew was observing R2 having multiple bruises during visits. The family stated that at the time Staff was unable to explain how R2 received the bruises and that at times, R2 was soiled and she could not find a caregiver to change him. R2 had numerous skin tears during his stay at the facility, but only one skin tear was documented in the facility’s communication notes dated 12/13/19. No other reports were completed for any other incidents/injuries. On 02/18/20, former employee identified as Witness 1 (W1) provided photographs of R1 and R2 with injuries. R2’s daughter in-law reported concerns to Administrator Pak about R2 becoming too thin and not being given enough food or water.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20191205134847
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: 10/08/2020
NARRATIVE
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On 01/29/20, W1 asked a caregiver if she had checked on R2 and gave him breakfast and was told no as the food was only delivered to residents with tickets and there was none generated for R2. W1 checked on R2 at 10 a.m. and found him unresponsive with no pulse, cold and stiff. W1 observed there was no water or Ensure at R2’s side table and said it appeared that no one had been in to check on R2 that morning. Per Death Certificate dated 01/31/20, R2’s estimated time of death was at 9:30 a.m. on 01/29/20. Administrator Pak reported to the IB Investigator that R2 passed surrounded by family and hospice during the time of death, however R2’s daughter in-law reported the family received a phone call after R2 died, and Hospice arrived after the family arrived. There is enough information to show that R2 did not receive adequate care in which R2 sustained unreported injuries and was failing to thrive becoming very thin and weak to support the allegation of Neglect/Lack of Care and Supervision.

Based upon review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. See LIC9099D for cited deficiencies per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted with Hope Pak via telephone and a copy of this report along with the 811 was provided to via email and an electronic email read receipt confirms receiving these documents. Administrator Hope Pak has agreed to sign and return report to LPA.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20191205134847
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: 10/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2020
Section Cited
CCR
87464(f)(1)
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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 regulation was not met as evidenced by: Licensee did not ensure that adequate care and supervision was provided to R1 and R2 as evidenced by R1 not provided medical attention to an
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Administrator to submit a detailed written plan on ensuring resident’s basic needs will be provided and forward proof to CCL by POC due date of 10/12/2020
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unwitnessed injury to the head and R2 sustaining unreported injuries and not receiving assistance with food and water intake. R2 did not receive breakfast on the morning of 1/29/20. This poses a serious immediate risk to the residents in care.
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Civil penalty assessed for repeat violation.
Type A
10/12/2020
Section Cited
HSC
1569.50(a)(3)
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Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by: Administrator Hope Pak reported R2 passed away surrounded by family and hospice during time of death.
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Administrator to submit a statement of understanding of the regulation cited and submit proof to CCL by close of business day of 10/12/2020.
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However, Family and Hospice corroborated receiving the call after R2 passed away and arriving to the facility after the R2’s death. This poses an immediate risk to the health and safety of residents 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) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20191205134847
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: 10/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2020
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency…(1) A written report shall be submitted to the licensing agency…(D) Any incident which threatens the welfare, safety or health of any resident…This regulation was not met as evidenced by:
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Administrator to submit a statement of understanding of the regulation cited and submit proof to CCL by close of business day of 10/12/2020.
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During investigation, it was determined the Licensee did not report serious injuries of R1 and R2 and the R2’s death to Licensing. This poses and immediate risk to the health and safety of residents in care.
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Civil penalty assessed for repeat violation.
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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) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5