FILED 00 JUN IG PHI2:52 AGENCY FOR HEALTH CARE ADMINISTRATION pjyicigy: of ADMINISTRATIVE STATE OF FLORIDA, AGENCY FOR HEARINGS HEALTH CARE ADMINISTRATION, STATE OF FLORIDA Petitioner, AHCA No.: 04-00-006-ALF 00-RYKS | vs. ALS LEASING, INC., d/b/a ALTERRA CLARE BRIDGE OF JACKSONVILLE, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY notified that after twenty-one (21) days from the receipt of this Complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency”) intends to impose a civil penalty in the amount of $600.00 upon ALS LEASING, INC., d/b/a ALTERRA CLARE BRIDGE OF JACKSONVILLE, (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part III, Florida Statutes. (2) Respondent is licensed to operate an Assistant Living Facility at 10050 Old St. Augustine Road, Jacksonville, Florida 32257, in compliance with Chapter 400, Part Ii, Florida Statutes, and Rule 58A-5, Florida Administrative Code. (3) The Respondent has violated the provision of Chapter 400, Part -II, Florida Statutes, and provision of 58A-5, Florida Administrative Code, in that it was cited for two Mo oS) (2) Class IMT deficiencies at an ALF change of ownership; limited nursing services and extended congregate care inspection on February 4, 2000. These deficiencies set forth below, were previously cited at a biennial licensure inspection on September 2, 1999, and constitute repeat deficiencies: (a) (A203) The Respondent failed to maintain an up to date written_admission and discharge record of all residents, including emergency temporary services placements. This is a violation of Section 400.419 (1)(c), Florida Statutes (1999), and Rule 58A-5.024 (1)(a), Florida Administrative Code. Class III deficiency. Fine: $300.00 (b) (A610) The Respondent failed to keep centrally storage medication in a locked cabinet or storage area at all times. The is a violation of Section 400.419 (1)(c), Florida Statutes (1999), and Rule 58A- 5.0182(6)(d) 3a, Florida Administrative Code. Class [I deficiency. Fine: $300.00. (4) Notice was provided in writing to the Respondent of each of the above violations and the time frame for correction. The Agency is authorized to impose this fine penalty pursuant to Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A-5, Florida Administrative Code. . -- (5) Respondent is notified that it has a right to request an administrative hearing ' pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross examine witnesses, to have subpoenas and/ or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. Chapter 59-1, Part 2, Florida Administrative Code, constitutes the Agency’s procedural rule for administrative proceedings resulting from this complaint. In order to obtain a formal proceeding under Section 120.57, (1) Florida Statutes, your request for an + Ww Y administrative hearing must conform to the requirements in Rule 10E-12.106, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of the fact in your request for a hearing may be treated by the Agency as election by you of an informal proceeding under Section 120.57 (2), Florida Statutes. All requests for hearings shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, Suite 3431, 2727 Mahan Drive, Tallahassee, Florida 32308; Attention: Michael O. Mathis, Senior Attomey. Payment of fines shall be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Florida 32317-3749 (Please reference the number and facility name on the front of your check.) (6) Respondent is further notified that failure to request a hearing within twenty- one (21) days of receipt of this complaint will result in an admission of the facts alleged in the complaint and the entry of a final order by the Agency. CER’ CATE OF SER I HEREBY CERTIFY that a true copy hereby was sent U S. Certified Mail, Return Receipt Requested, to Nancy Crick, Administrator, Alterra Clare Bridge of Jacksonville, 10050 Old Augustine Road, Jacksonville, Florida, 32257 on this > say of oc: / 2000. Copies Furnished to: Michael! O. Mathis, Esquire - Senior Attorney Agency for Health Care Administration 2727 Mahan Drive Building #3 Tallahassee, FI. 32308 Nancy Crick, Administrator Alterra Clarer Bridge of Jacksonville 10050 Old Augustine Road Jacksonville, Florida 32257 WY Karen K. Swann ) Area #4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 N. Davis Street Bldg. A, Suite 115 Jacksonville, FL 32209 Finance & Accounting Agency for Care Administration Bldg. 2, 2% Floor 2727 Mahan Drive Tallahassee, Florida 32308 Karen Swann Area #4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 North Davis Street, Suite 115 Jacksonville, Florida 32209

Docket for Case No: 00-002483