306005182-3-22-2021-22-AS-SHAD-BZCTPX-20210322145505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005182
Report Date: 03/22/2021
Date Signed: 03/22/2021 02:55:24 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 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:	340	CENSUS: 81	DATE:	03/22/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Monica Kim		TIME COMPLETED:	02:45 PM

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	On 3/22/21, Licensing Program Analyst (LPA) Sean Haddad made an unannounced Plan of Correction inspection to verify correction of deficiencies issued during the inspection conducted on 3/8/21 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 this inspection, the LPA observed the following: 1. Deficiency cited under Title 22 Regulation 87303(a) pertaining to maintenance issues, broken lights, exposed screws, etc. was addressed. LPA was provided lists and photos of repairs. During today’s inspection, LPA inspected affected Rooms 120, 207, 209, 212, 214, 233, 242, and 249 and observed significant progress has been made and OM agreed to submit proof of completion by 3/23/21. 2. Deficiency cited under Title 22 Regulation 87307(d)(2) pertaining to sanitation issues, feces, diapers, etc. was addressed. LPA was provided lists and photos of repairs. During today’s inspection, LPA inspected affected Rooms 116, 117, 118, 119, 120, 205, 209, 212, and 215 and observed significant progress has been made and OM agreed to submit proof of completion by 3/23/21. 3. Deficiency cited under Title 22 Regulation 87303(i)(1) pertaining to non-functioning call system has been CLEARED. LPA was provided timesheets showing the call system was staffed during the night shift and a list of repairs showing the issue was addressed. During today’s inspection, LPA observed the call systems in affected Rooms 116 and 214 to be repaired. Licensee has complied with the terms of the POC by POC due date. 4. Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to accessible dangerous items, such as knives, has been CLEARED. The facility corrected the identified deficiencies during the previous inspection on 2/16/21. LPA was provided a list of repairs showing the facility searched for and addressed the same issue throughout the facility. During today’s inspection, LPA visually confirmed the corrections in affected Rooms 101, 228, 237, 260, and 381. As of today’s inspection, the POC has been properly cleared.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 03/22/2021

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5. Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to accessible dangerous substances, such as medications, has been CLEARED. The facility corrected the identified deficiencies during the previous inspection on 2/16/21. LPA was provided a list of repairs showing the facility searched for and addressed the same issue throughout the facility. During today’s inspection, LPA visually confirmed the corrections in affected Rooms 101, 234, 260, and 381. Licensee has complied with the terms of the POC by POC due date.

6. Deficiency cited under Title 22 Regulation 87411(d)(2) pertaining to lack of laundry staff training has been CLEARED. LPA was provided with the housekeeping duties list, training logs, and a photograph of signage added to the affected laundry room identifying placement of soiled and clean fabrics. As of today’s inspection, the POC has been properly cleared.

7. Deficiency cited under Title 22 Regulation 87355(e)(2) pertaining to Staff Member #1’s (S1) background check clearance transfer has been CLEARED. LPA was provided with an association request for S1 and a printout of the Guardian association list indicating all facility staff are associated. LPA also confirmed on 3/17/21 that S1 was associated on Guardian. Licensee has complied with the terms of the POC by POC due date.

8. Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to failure to give medications has been CLEARED. LPA was provided with a plan to ensure all residents are provided assistance with taking prescribed medications. During today’s inspection, LPA confirmed with med tech Staff Member #2 (S2) that facility staff members were trained on the submitted plan. As of today’s inspection, the POC has been properly cleared.

9. Deficiency cited under Title 22 Regulation 87303(e)(2) pertaining to water exceeding regulatory temperature has been CLEARED. LPA was provided lists and photos of repairs. During today’s inspection, LPA visually confirmed the water temperature in affected Rooms 213 (114.8 degrees F) and 218 (115.5 degrees F) to be within the regulatory range. Licensee has complied with the terms of the POC by POC due date.
An exit interview was conducted with Facility representative via tele-visit. This report 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 Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC809 (FAS) - (06/04)

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