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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 03/08/2021
Date Signed: 03/09/2021 01:51:24 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: 84DATE:
03/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Monica KimTIME COMPLETED:
06:00 PM
NARRATIVE
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On 3/8/21, Licensing Program Analyst (LPA) Sean Haddad made an unannounced inspection for the purpose of issuing citations for deficiencies observed during a Case Management visit conducted on 2/16/21 via tele-visit due to COVID-19 and for precautionary measures. LPA met with Operating Manager (OM) Monica Kim and explained the reason for today’s inspection.

During the inspection on 2/16/21, Acting Regional Manager (ARM) Marina Stanic, Acting Licensing Program Manager (ALPM) Valarie Cook, LPA, and California Department of Public Health (CDPH) Health Facilities Evaluator Nurses (HFEN) Shinhee Kim and Seung Hye Jung toured the facility, observed residents and staff, observed the food, interviewed residents and staff, obtained and reviewed documents, and made the following findings.

At 9:15 AM, LPAs entered the facility and observed residents in the common areas and hallways not wearing masks. Upon entering the first-floor memory care with Activity Director, James Lee, LPAs observed 31 residents not wearing masks or social distancing in the common area and hallway. Upon learning of LPAs’ presence at the facility, facility staff began providing masks to the residents and helping the residents put them on. During the inspection, LPAs interviewed OM and Assistant Administrator (AAD) Erik Doan who confirmed that between 3/1/20 and 2/16/21, the facility conducted COVID testing only once on 11/18/20. OM confirmed the facility is not conducting any on-going surveillance testing of staff or residents.

At 9:25 AM, LPAs began touring the first-floor memory care section with Activity Director James Lee and observed no activities calendar posted in the memory care section. LPAs also observed memory care residents in the common area, sitting silently with no activities. By the time LPAs left the memory care section at 11:00 AM, the residents were still sitting silently with no activities. OM confirmed the memory care was without an activities calendar.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: (a) ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure safe and healthful accommodations to residents by not having them socially distant and wearing masks during pandemic, which poses a potential personal rights risk to persons in care.
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Type B
03/15/2021
Section Cited

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87219 Planned Activities: In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents... This requirement was not met as evidenced by:
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Based on observation, the licensee did not post an activities calendar in the memory care section, which poses a potential health and 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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2021
Section Cited

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87307 Personal Accommodations and Services: (a)(3) … the licensee shall assure provision of: (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings... This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure the closets were functional and accessible in Rooms 127, 120, 116, 223, 224, 209, 233, 227, 209, 253, and 207, which poses a potential safety and personal rights risk to persons in care.
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Type B
03/15/2021
Section Cited

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87307 Personal Accommodations and Services: (a)(3) … the licensee shall assure provision of: (A) A bed for each resident … with good springs, a clean and comfortable mattress.... This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure the beds in Rooms 117, 123, 207, 221, and 234 had bedsprings, bedframes, and bedsheets, which poses a potential health and 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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87303 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: Based on observation, the licensee did not ensure the memory care hallway, outside furniture,
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and 8 out of 35 Rooms were clean and in good repair, which rooms contained missing lightbulb covers, slat blinds missing slats, sharp exposed screws on furniture, etc., which poses an immediate health and safety risk to persons in care.
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Type A
03/09/2021
Section Cited

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87307 Personal Accommodations and Services. (d) … (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure 9 out of 35 Rooms were safe and healthful, which rooms contained used/soiled diapers, foul odors, stains on walls, feces, etc., which 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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87303 Maintenance and Operation: (i)(1) …facilities licensed for 16… shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a... signal to a central staffed location or... summon staff... This requirement was not met as evidenced by:
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Based on observation and record review, the licensee did not ensure the call system was operational in Room 116, had a bathroom pull cord in Room 214, and was staffed during the nightshift, which poses an immediate health and safety risk to persons in care.
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and submit (A) a list of repairs made to LPA by POC due date and (B) timesheets showing the reception/call desk is staffed during nightshifts by four (4) weeks after POC due date.
Type B
03/15/2021
Section Cited

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87307 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:
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Based on observation, the licensee did not ensure at least 27 resident restrooms rooms had soap and toilet paper, and that the first floor bathrooms designated for public, staff, and resident use had paper towels, which poses a potential health and 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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: … (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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Based on observation and interview, the licensee did not ensure lighters, scissors, razors, hammers, and knives were secured and inaccessible in 5 out of 35 Rooms which dementia residents occupied or could enter, which poses an immediate health and safety risk to persons in care.
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Type A
03/09/2021
Section Cited

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: … (2) Over-the-counter medication, ..., alcohol, cigarettes, and toxic substances... This requirement was not met as evidenced by:
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Based on observation and interview, the licensee did not ensure medications and toxins were secured and inaccessible in 4 out of 35 Rooms which dementia residents occupied or could enter, which poses an immediate 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 6 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2021
Section Cited

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87219 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… This requirement was not met as evidenced by:
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Based on interview, the licensee did not ensure the activity director, S1, had full-time responsibility to organize, conduct and evaluate planned activities, which poses a potential health and personal rights risk to persons in care.
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Type B
03/15/2021
Section Cited

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87555 General Food Service Requirements: (b) The following food service requirements shall apply: … (6) … Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request. This requirement was not met as evidenced by:
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Based on observation and interview, the licensee did not post a menu for the Korean option for meals, was not able to provide one upon request, and did not follow the American menu’s main course, which poses a potential health and 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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 7 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87411 Personnel Requirements – General: (d) All personnel shall be given on the job training or have related experience in the job assigned … as evidenced by safe and effective job performance: (2) Housekeeping and sanitation principles. This requirement was not met as evidenced by:
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Based on observation, interview, and record review, the licensee did not ensure laundry staff were properly trained as evidenced by laundry staff cross-contaminating dirty and clean clothes, which poses an immediate health and safety risk to persons in care.
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Type B
03/15/2021
Section Cited

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87211 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:
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Based on review of records, the licensee did not report at least 5 hospitalizations and 12 deaths in the last 5 months, 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 8 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working ... (2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by:
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Based on record review, the licensee did not ensure S1’s criminal record clearance was transferred to the facility prior to S1 beginning work, which poses an immediate health and safety risk to persons in care.
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Type A
03/09/2021
Section Cited

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87464 Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident … with those activities of daily living such as … assistance with taking prescribed medications… This requirement was not met as evidenced by:
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Based on interviews and records reviewed, the licensee did not ensure R1 received 6 medications, which poses an immediate 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 9 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87303 Maintenance and Operation: (e) … (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water … of … not more than 120 degree F (49 degree C). This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure hot water delivered to 2 resident rooms fell between 105 and 120 degrees F, which poses an immediate health and safety risk to persons in care.
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and submit a temperature log to LPA by 2 weeks after POC due date.
Type B
03/22/2021
Section Cited

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87705 Care of Persons with Dementia: (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, ... include a reassessment of ... dementia care needs. This requirement was not met as evidenced by:
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Based on interviews and records reviewed, the licensee did not ensure R1 and R2 received an annual medical assessment and reappraisal, 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 10 of 15
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2021
Section Cited

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87707 Training Requirements If Advertising Dementia Special Care…: (a)(1)… six hours of orientation... (B)… exclusively on the care of residents with dementia. (C)1... up to two hours of mentoring and hands-on training... This requirement was not met as evidenced by:
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Based on interviews, the licensee did not ensure staff received required dementia training, as staff received 30-45 minute of video instruction and hands-on training is limited 2 hours, which poses a potential health, safety and/or personal rights risk to persons in care.
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with dementia have received the required training within two (2) weeks of POC due date.

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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) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 11 of 15
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: 03/08/2021
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At 9:35 AM, in the memory care section, LPAs observed a mattress lacking bedsprings in Room 123 and a bed without bedsheets in Rooms 117 and 123 (photos taken). LPAs later began touring the assisted living section with OM and Assistant Administrator (AAD) Erik Doan at 11:30 AM and observed beds without bedsheets in Rooms 207 and 234 and a mattress on the floor without a bed frame in Room 221 (photos taken). An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

In the memory care section, LPAs observed large closet doors missing, stuck in their railings, or falling out of their railings in Rooms 127, 120, and 116, rendering operation of the closet doors both difficult and hazardous (photos taken). In the assisted living section, LPAs also observed the large closet doors in Rooms 223, 224, 209, 233, 227, 253, and 207 in the same condition (photos taken).

In the memory care section, LPAs observed a chair covered in bird feces in the sitting area outside memory care accessible to residents, a fluorescent light bulb exposed without a cover in the memory care hallway, slat blinds missing slats in Room 120, and broken furniture with sharp exposed screws in Room 120 (photos taken). In the assisted living section, LPAs also observed a fluorescent light bulb exposed without a cover in Room 207, slat blinds missing slats in Room 209, broken furniture with sharp exposed screws in Room 233, a broken towel hanger in Room 233, a bathroom light bulb out and an air vent system that does not create suction in Room 214, a bent curtain rod and chair cushion with stuffing exposed in Room 212, air conditioning not working in Room 249, no light in Room 242, and a hole in the door of Room 209 (photos taken). An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

In the memory care section, LPAs observed soiled diapers in the shower and dresser of Room 120, a foul odor in Room 118, a brown stain on the wall of Room 117, a soiled diaper on the bathroom floor, feces in the toilet, on the bathroom floor, and on a bed and chair in Room 119, a soiled pad on the bed in Room 116, and heavily stained carpet in Room 116 (photos taken). In the assisted living section, LPAs also observed feces in the toilet of Room 205, heavily stained carpet in Room 209, crumbs on floor of Room 209, dirty toothbrushes near the bathroom sink in Room 212, and a stain under the bathroom sink in Room 215 (photos taken).
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 12 of 15
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: 03/08/2021
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In the memory care section, LPAs observed multiple resident bathrooms lacking soap and/or toilet paper, including Rooms 127, 129, 123, 120, 125, 118, and 119. In the assisted living section, LPAs also observed multiple resident bathrooms lacking soap and/or toilet paper, including Rooms 227, 224, 223, 220, 207, 202, 215, 205, 212, 209, 230, 233, 208, 237, 234, 242, 253, 256, and 259 and the second floor bathrooms designated for public, staff, and resident use lacking paper towels (photos taken). An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

In the memory care section, LPAs observed the call system was nonoperational in Room 116 (photos taken). In the assisted living section, LPAs also observed the call system lacked a bathroom pull cord in Room 214. During the inspection, LPAs requested and reviewed staffing schedules and staff timesheets demonstrating the call system is not staffed during the night shift, so no resident signals are received or answered during that shift. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

In the memory care section, LPAs observed a lighter, scissors, toxins, electric kettle, and razors in Room 101— unsecured, visible, and accessible to residents (photos taken). In the assisted living section, LPAs also observed an electric pot and electric kettle in Room 228, an electric kettle in Room 237, a hammer, scissors, an electric kettle, and a microwave in Room 260, and a knife in Room 381—all unsecured, visible, and accessible to residents (photos taken). During the inspection, LPAs interviewed OM who stated that at least 2 memory care residents spend their days in the first-floor memory care section, but sleep in a room in the second floor assisted living section.

In the memory care section, LPAs observed over the counter pain relievers and prescription cholesterol, bipolar disorder, dementia, and antipsychotic medications in Room 101—all unsecured, visible, and accessible to residents (photos taken). In the assisted living section, LPAs also observed rubbing alcohol in Rooms 234, over the counter pain relievers and prescription medications in Room 260, and over the counter pain relievers and prescription antibiotic medications in Room 381—all unsecured, visible, and accessible to residents (photos taken). An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 13 of 15
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: 03/08/2021
NARRATIVE
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During the inspection, James Lee reported to LPAs that he also is assigned to housekeeping and maintenance duties in addition to being the Activity director. OM confirmed James Lee handles housekeeping duties. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

At 11:00 AM, LPAs toured the dining room / kitchen area on the second floor and observed residents eating lunch. LPAs observed that no menu for the Korean option for meals was posted. LPAs requested a copy of the Korean menu, but the facility staff were unable to provide a menu. At 4:45 PM, LPAs observed residents eating dinner. The dinner menu identified the main course as “Teriyaki Beef 4oz”, but LPM Cook observed the portion served to residents to be smaller than 4oz.

In the assisted living section, LPAs interviewed Staff Member #1 (S1) who was observed doing laundry in the small laundry room. S1 stated they only use a small amount of detergent when doing laundry and do not use disinfectant. LPAs followed S1 to the large laundry room on the second floor and observed dirty and clean laundry cross-contaminating without proper separation. LPAs requested and reviewed S1’s resident file which showed no training on the laundry process.

At 12:40 PM, LPAs left the facility, returned at 2:10 PM, and began reviewing documents in the activity room on the second floor with OM and AAD. LPAs requested and reviewed the facility communications log and hospice list which described reportable hospitalizations dated 10/5/20, 10/30/20, 11/5/20, 12/2/20, 12/18/20 and deaths dated 11/8/20, 11/12/20, 11/19/20, 12/20/20, 11/30/20, 12/20/20, 1/5/21, 1/8/21, 1/9/21, 1/19/21, 1/21/21, and 2/1/21. OM stated these incidents had not been reported to CCLD and LPA Haddad subsequently confirmed they had not been reported based on CCLD Incident Report Log. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

LPAs requested and reviewed Staff Member #1’s (S1) staff file, did not find a background clearance transfer, and checked the Licensing System Information on 2/16/21 which showed S1’s criminal record clearance had not been transferred to the facility prior to S1 starting work on 10/21/20. S1 works 5 days a week based on S1’s staff file and the facility’s schedule. A civil penalty in the amount of $500 is being assessed for S1 working at facility over 5 days without a clearance transfer.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 14 of 15
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: 03/08/2021
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LPAs requested and reviewed medication records for Resident #1 (R1) which showed 6 medications were not administered and confirmed these findings via interview with OM.

LPAs requested and reviewed a physician’s reported dated 2/24/17 for Resident #2 (R2) showing the physician’s report and dementia diagnosis was not updated annually and confirmed these findings via interview with AAD. LPAs reviewed physician’s report dated 6/9/18 for R1 and medical records demonstrating a medication had been added for dementia and confirmed with OM that no updated physician’s report had been obtained by the facility in response to the new condition.

At 3:30 PM, LPA Haddad went to the second floor assisted living section with AAD and tested the water temperature in 4 rooms and the hot water delivered to Rooms 218 and 213 was tested to be 126.3 degrees F. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/14/2020. The civil penalty shall be assessed until the violation is corrected.

At 4:00 PM, LPA Haddad interviewed 2 caregivers who provide direct care to memory care residents, both of whom reported that the facility’s training for working with dementia residents is limited to watching a 30-45 minute video and a week or less of shadowing another caregiver. LPAs later requested and reviewed training records dated 8/15/20 titled “Re: How to Take Care of Residents in Memory Care” but not specifying the length of the training, its subject matter, and whether it had been developed by or in consultation with individuals or organizations with expertise in dementia care. At 5:00 PM, LPAs concluded the inspection and advised facility representative that additional review of documents would be required before delivering findings. At 5:30 PM, LPAs left the facility.

Based on the observations made during the 2/16/21 inspection, violations are being cited per Title 22 of the California Code of Regulations. See LIC809D. Civil penalties in the amount of $500 are being assessed because a staff member worked over 5 days without a clearance transfer. See LIC421BG. Based on review of the facility's compliance history, which revealed the licensee was cited for the same violations within the last 12 months, civil penalties in the amount of $250 per repeat violation are being assessed. Civil penalties of $100 per day, per violation will accrue until the deficiencies are corrected. See LIC421FC. An exit interview was conducted with Facility representative via tele-visit. This report as well as Appeal Rights will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to send a signed copy by email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 15 of 15