CY ACIE STATE OF FLORIDA 046 Juy AGENCY FOR HEALTH CARE ADMINISTRATION “3 PM br 19 OVI St ay. AGENCY FOR HEALTH CARE ADM): ISTP; ADMINISTRATION, HE Abin ok TQS Petitioner, AHCA No.: 2004003129 v. Return Receipt Requested: 7002 2410 0001 4237 1055 PUBLIC HEALTH TRUST OF MIAMI-DADE 7002 2410 0001 4237 1062 COUNTY, d/b/a JACKSON NORTH CMHC- SERENITY HOME, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against The Public Health Trust of Miami-Dade County, d/b/a Jackson North CMHC- Serenity Home (hereinafter “Jackson North CMHC-Serenity Home”), pursuant to Chapter 400, Part III and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $500.00 pursuant to Sections 400.414 and 400.419(1) (c) Florida Statutes (2003) for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28- 106, Florida Administrative Code. 3. Venue lies in Miami-Dade County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2003) and Chapter 58A-5 Florida Administrative Code. 5. Jackson North CMHC-Serenity Home operates a 6-bed assisted living facility located at 480 N.W. 123" Street, Miami, Florida 33163. Jackson North CMHC-Serenity Home is licensed as an assisted living facility under license number 8793. Jackson North CMHC-Serenity Home was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I JACKSON NORTH CMHC-SERENITY HOME FAILED TO SUBMIT AN ANNUAL UPDATED EMERGENCY MANAGEMENT PLAN TO COUNTY OFFICIALS FOR APPROVAL. Section 400.441(1) (b), Florida Statutes, and/or Rule 58A-5.026(2) (c), Florida Administrative Code (EMERGENCY MANAGEMENT) CLASS III 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the change of ownership survey conducted on 02/11/2004 and Based on observation, interview and record review, the facility failed to submit an updated emergency management plan to county officials for approval. 8. On 02-11-04 at llam, review of facility records and interview with the supervisor, revealed the facility did not have an approved up-dated emergency management plan on file. The supervisor was unable to provide the last up-dated plan. Correction Date:03-11-04. 9. During the follow up survey conducted on 3/12/2004 and based on observation, interview and record review, the facility still failed to submit an updated emergency management plan to county officials for approval. 10. On 03/12/2004 at 11:30 am, review of facility records and interview with administrator revealed that the facility did not have an approved up-dated emergency management plan on file. The administrator was unable to provide the last approved plan. 11. Based on the foregoing, Jackson North CMHC- Serenity Home violated Section 400.441(1) (b), Florida Statutes, and/or Rule 58A-5.026(2) (c), Florida Administrative Code, herein classified as an uncorrected Class III violatior, which warrants an assessed fine of $500.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Jackson North CMHC-Serenity Home on Count I. 2. Assess an administrative fine of $500.00 against Jackson North CMHC-Serenity Home on Count I for the violation cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECHIVE A REQUEST FOR 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. te A. be UM la. Bar 997315 Assistant General Counsel Agency for Health Care Administration 8350 N. W. Miami, Copies furnished to: Diane Lopez Castillo9 Field Office Manager Agency for Health Care Administration 8355 N.W. 53° Street, 1°° Floor Miami, Florida 33166 (Interoffice mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Florida 33166 Esq. 52°? Terrace CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Barbara C. Bush, Administrator, Jackson North CMHC-Serenity Home, 480 N.W. 12374 Street, Miami, Florida 33168 and to The Public Health Trust of Miami-Dade County, 20201 N.W. 372 Avenue, Opalocka, Florida 330560n this 2? “Ziny of Atpacl , 2004.

Docket for Case No: 04-002036