oe STATE OF FLORIDA Ap “ee ., 7 & L 8 Lp. oa Sat AGENCY FOR HEALTH CARE ADMINISTRATIO) Boy Pe ty MES 8 ag Pee 5 ifs 8 STATE OF FLORIDA Shan AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 06-01-0129-ALF ALTERRA HEALTHCARE CORPORATION, d/b/a ALTERRA CLARE BRIDGE OF LAKELAND, 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 $1,000.00 upon Alterra Healthcare Corporation d/b/a Alterra Clare bridge of Lakeland (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 605 Carpenter’s Way, Lakeland, Florida 33809, in compliance with Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated minimum licensure standards, as evidenced by each deficiency set forth below, as found to exist during the survey of June 5, 2001: (a) The Respondent failed to make every reasonable effort to ensure that a prescription for a resident who received assistance with self-administration or medication administration was refilled in a timely manner. This is a violation of Section 400.419(1) (b), Florida Statutes, and Rule 58A-5.0185(7) (f), Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (4) The above referenced violation constitutes grounds to levy this civil penalty pursuant to Section 400.419, Plorida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an Assisted Living Facility. (5) Notice was provided in writing to the Respondent of each of the above violations and of the time within which correction was required. (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 requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Division of Managed Care and Health Quality, 525 Mirror Lake Drive North, Suite 310d, St. Petersburg, Florida 33701; attention Patricia J. Hakes, 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 has been sent by U.S. Certified Mail, Return Receipt (2 170 444 479) Requested, to Alterra Healthcare Corporation, through its Registered Agent CT Corporation System, 1200 South Pine Island Road, Plantation FL 33324, on the 2”*, day of eguak , 2001. Fae. Chip mn PATRICIA RE CAUFMAN Field Office Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: Patricia J. Hakes, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 3103 St. Petersburg, Florida 33701 ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (By inter-office mail) Area 6 Office Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 410A St. Petersburg, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (By inter-office mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (By inter-office mail)

Docket for Case No: 02-002010