ne STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINI STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, petitioner, AHCA NO: 2001058071 vs. 04-01% OAKLAND MANOR, Respondent. STRATIVE COMPLAINT ADMINI COMES NOW the agency for Health Care administration (hereinafter YAHCA”), BY and through the undersigned counsel, and files this administrative complaint, against OAKLAND MANOR, (hereinafter “Respondent”) and alleges: NATURE _OF THE ACTION 1. This is an action to impose an administrative fine in the amount of One Thousand Dollars ($1,000) pursuant to Sections 400.414 (1) (a) and 400.419 (1) (¢) Florida statutes. 2. The Respondent was originally cited for the deficiencies set forth below as a result of an appraisal visit survey in conjunction with Operation Spot Check conducted on oF about March 12, 2001. On 9/18/01 an appraisal/monitoring visit was conducted in which a repeat deficiency was discovered. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part III, Florida Statutes. 4. venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. PARTIES 5. AHCA, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part Ill, Florida Statutes and Rules SBA-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 2812 North Nebraska Avenue, Tampa, Florida 33602. The facility is licensed under Chapter 400, Part Til, Florida Statutes and Chapter 58A-5, Florida Administrative Code. couNT I RESPONDENT FAILED TO MAINTAIN THE REQUIRED MINIMUM STAFF HOURS PER WEEK VIOLATING Fl. Admin Code R. 58A-5.019 (4) (a) 1. REPEAT CLASS IIT DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about March 12, 2001 4 survey of the facility was conducted 9. on that date, based on review of the staff work schedule, it was determined that the facility did not maintain the required minimum staff hours per week for a census of 25. 10. on or about September 18, 2001 a monitoring visit was conducted at the facility. 11. on that date, based on a review of the posted September schedule and on interview with the Administrator, the facility is not maintaining minimum staff hours for their current census of 16. The facility is required to have 4 minimum of 253 hours scheduled (and worked) per week for their current census; however, 4 review of the schedule provided by the Administrator showed only 208 direct care hours. This is a repeat deficiency from the 3/12/2001 survey. 12. The above referenced violation constitutes the grounds for the one (1) imposed repeat Class IIT deficiency and for which a fine of One Thousand Dollars ($1,000) is authorized under §400.419(1) (c) Florida Statutes. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count IT; B. Impose a total fine of One Thousand Dollars ($1,000) for the violation cited in Count I, against the respondent under §400.419(1) (c) Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to §400.121(2) Florida Statutes, and D. All other general and equitable relief allowed by law. NOTICE OAKLAND MANOR is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page) . All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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 . Eileen O’Hara Ggrcla, Esquire AHCA -— Senior Aptorney Fla. Bar No. 505149 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, Lisa McCarthy, 13807 Shady Shores Drive, Tampa, Florida 33612, U.S. Mail Certified Return Receipt No. 7002 2030 0002 7109 5349, and Roger D. Reynolds, 9063 East River Road, Venice, Florida ( 34293, U.S. Mail on November 1 , 2002. Eileen O'Hara Garcia, Esquire Copies furnished to: Lisa McCarthy Administrator/Owner of Oakland Manor 13807 Shady Shores Drive Tampa, Florida 33612 (U.S. Certified Mail) Roger David Reynolds Corporate Officer for Oakland Manor 9063 East River Road venice, Florida 34293 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Alberta Granger Assisted Living Facilities Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS Code #30 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701

Docket for Case No: 03-000163