STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION i ! L Ep STATE OF FLORIDA O1 FEB ig AM 10: 25 AGENCY FOR HEALTH CARE DiVis;, ADMINISTRATION, ADM) iSIGy or HES IRATIVE Petitioner, ARINGS vs. AHCA NO: 06-00-124-ALF D1 oes PALMETTO GUEST HOME (Palmetto Guest Home, Inc., d/b/a Palmetto Guest Home), 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 $400.00 upon Palmetto Guest Home (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 as an Assisted Living Facility at 820 5° street West, Palmetto, Florida 34221, in compliance with Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part III, Florida Statutes, and provisions of Chapter 58A- 5, Florida Administrative Code, in that it repeated and/or failed to correct, within the mandated time frame, one (1) deficiency cited during the survey of May 15, 2000. This deficiency, set forth below, were previously cited at the licensure survey of March 30, 2000: (a) The Respondent failed to ensure that fire safety standards were met in that the facility did not have current fire inspection. This is a violation of Sections 400.419(1) (c), and 400.414 (k), Florida Statutes, and Rule 58A-5.015(1) (a) (3), Florida Administrative Code. Class III deficiency. Fine: $400.00. (4) The above referenced violation constitutes grounds to levy this civil penalty pursuant to Section 400.414, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an ALF (Assisted Living Facility). (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. (6) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, 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 II, Florida Administrative Code, constitutes the Agency’s procedural rules 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 administrative hearing must conform to the requirements in Rule 28-106, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), Florida Statutes. All request for hearings shall be made to the Agency for Health Care Administration, and delivered to Division of Health Quality Assurance, 6800 North Dale Mabry Highway, Suite 220, Tampa, Florida 33614; attention Michael R. Hope, Senior Attorney. Payment of fines shall be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Florida 32317-3749. (Please reference the case number and facility name on the front of your check). (7) RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEPT 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. I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt (Number Z 366 321 443) Requested, to V. William Kaklis, Registered Agent for The Palmetto Guest Home, Inc., 1400 4° avenue West, Bradenton, Florida 34205, on the LTA day of Sie ceee Le/~ 2000. Abu ALICE R Field Office Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Administrator Palmetto Guest Home 820 5° Street West Palmetto, Florida 34221 in compliance with Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part III, Florida Statutes, and provisions of Chapter 58A- 5, Florida Administrative Code, in that it repeated and/or failed to correct, within the mandated time frame, one (1) deficiency cited during the survey of May 15, 2000. This deficiency, set forth below, were previously cited at the licensure survey of March 30, 2000: (a) The Respondent failed to ensure that fire safety standards were met in that the facility did not have current fire inspection. . 1401) CK) This is a violation of Sections, 400.419(1) (c), ane 400. 47K) , set °F, 33 tl) 3) Florida Statutes, and Rule 58A-5-023/17) (a), Florida Administrative Code. Class III deficiency. Fine: $400.00. (4) The above referenced violation constitutes grounds to levy this civil penalty pursuant to Section 400.414, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an ALF (Assisted Living Facility) .

Docket for Case No: 01-000684