STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION nar buy {29 0 . dbu9 AVY et ray G 29 CARING NURSES ALF, INC., Petitioner, v. AHCA NO. 2004007746 DOAH CASE NO: 04-3844 STATE OF FLORIDA osm AGENCY FOR HEALTH CARE Or ADMINISTRATION, oa 2, ~ Respondent. es ” Pott ey 2 oe ~ ote gv us oO FINAL ORDER Having reviewed the Notice of Intent to Impose Late Fine dated August 20, 2004, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 2), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. The Petitioner shall withdraw its Petition for Formal Administrative Proceedings. 3. The Petitioner shall pay an administrative fine in the amount of $3,750.00. 4. This amount is due and payable within thirty (30) days of the date of rendition of this Order. 5. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to these case numbers, should be sent directly to: Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 6. Unpaid fines will be subject to statutory interest, and may be collected by all methods legally available. 7. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement. 8. The above styled case is hereby dismissed. 9. Each party shail bear its own costs and attorneys fees. DONE and ORDERED this day of Cbparsd. , 2005, in Tallahassee, Leon County, Florida. eee Alan Levin&, Secretary Agency for Health Care Administratio A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Helen Padilla, R.N. Owner/Administrator Caring Nurses, ALF, Inc. 900 South Highland Avenue Clearwater, Florida 33756 (U. S. Mail) Daniel Manry Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Alberta Granger, Manager Assisted Living Unit Bureau of Long Term Care Services (Interoffice Mail) Kimberly M. Nicewonder-Murray Senior Attorney Agency for Health Care Administration 525 Mirror Lake Dr. N., #330D St. Petersburg, Florida 33701 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive, MS#14 Tallahassee, Florida 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, Bldg#1, MS#9 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS#3 Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the , 2005. FOP Agency f@r Health Gare ini 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 SORIDA AGENCY FOR HEALTH CARE ADMINGSTRATION JEB BUSH, GOVERNOR ALAN LEVINE, SECRETARY Certified Article Numb , CERTIFIED MAIL RETURN aneeney abaabiieel RECEIPT REQUESTED -FULO 3903 Wha S32eb.2772 | SENDERS RECORD August 20, 2004 : Helen Padilla Caring Nurses ALF 900 Highland Avenue South Clearwater, FL 33756 RE: CC# 2004007746 NOTICE OF INTENT TO IMPOSE LATE FINE Dear Ms. Padilla: A fine of $5,000 is hereby imposed pursuant to Section 400.419(9), Florida Statutes (.S.) due to Caring Nurses ALF’s late filing of the change of ownership (CHOW) application for Caring Nurses assisted living facility. The SPECIFIC BASIS for the decision to impose a fine is: December 26, 2003 indicated that the licensee of Caring Nurses ALF would be a general partnership consisting of the following partners (Philip Mamaclay, Kimberly Howard, Helen Padilla, Bernardita Balderian). A standard license with limited nursing services (LNS) was issued to the general partnership for the period of 3/4/2004 — 3/3/2006. The applicant submitted an ALF application on August 10, 2004, requesting to add a specialty limited mental health (LMH) license. Page 4 of the application indicates that the facility owner is now under the corporate name of Caring Nurses ALF, Inc. Florida Department of State, Division of Corporations lists the date filed for Caring Nurses ALF, Inc. as April 22, 2004. The filing date of this corporation is after the initial submission of the licensure application. TO PAY NOW: PAYMENT SHOULD BE MADE TO: AGENCY FOR HEALTH CARE ADMINISTRATION, ASSISTED LIVING UNIT, 2727 MAHAN DR., TALLAHASSEE, FL 32308 ALONG WITH A COPY OF THIS NOTICE OF INTENT. 2727 Mahan Drive © Mail Stop #30 Tallahassee, FL 32308 Caring Nurses ALF August 20, 2004 Page 2 EXPLANATION OF RIGHTS Pursuant to Section 120.569, Florida Statutes, (F.S.) you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. . If you do not dispute any issues of material fact (you admit them), you will be afforded an informal hearing under Section 120.57(2), F.S. At an informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Notice of Intent. All requests for hearings shall be filed with the Agency within twenty-one (21) days of receipt of this letter. Failure to submit either payment or a request for hearing will result in the entry of a ‘final order imposing the fine sought. Any request shall be sent to Alberta Granger, Unit Manager, Assisted Living Unit, Agency for Health Care Administration, 2727 Mahan Drive, © Mail Stop 30, Tallahassee, FL 32308. Please include a copy of this Notice of Intent with the request. Sincerely, Assisted Living Unit Bureau of Long Term Care Services AG/cc ‘Article Number COMPLETE THIS SECTION ON DELIVERY “econ | UNE CERTIFIED MAILRETU; 340 3 NS SHEL 2772 _ ; RECEIPT REQUESTED [= oa j._“4° Restricted Delivery? (Extra Fee) j2 1. Article Addressed to: i August 20, 2004 Helen Padilla ; te A.L.UNIT Caring Nurses ALF : HELEN PADILLA ‘AUR 9.7 204 900 Highland Avenue So CARING NURSES ALF AUR ¢. Clearwater, FL 33756 900 HIGHLAND AVENUE SOUTH HEALTH FACILITY COMPLIANCE CLEARWATER, FL 33756 RE: 11966185 SENDER: 11, 05, MS #30 RE: .CC# 2004007746 NO; a a 2) ~ Dear Ms. Padilla: . cree, MO ert, PS Form 3811, July 2001 A fine of $5,000 is hereby imposed pursuant to Section 400.419(9), Florida Statutes. F.S.) aif tor Caring Nurses ALF’s late filing of the change of ownership (CHOW) application for Caring? Nurses assisted living facility. 4 ~, The SPECIFIC BASIS for the decision to impose a fine is: The applicant’s failure to submit a change of ownership application to the Agency for a new license at least 60 days before the date of transfer of ownership in accordance with Section 400.412(1), F.S. Specifically, an initial application submitted to the Agency by the applicant on December 26, 2003 indicated that the licensee of Caring Nurses ALF would be a general partnership consisting of the following partners (Philip Mamaclay, Kimberly Howard, Helen Padilla, Bernardita Balderian). A standard license with limited nursing services (LNS) was issued to the general partnership for the period of 3/4/2004 — 3/3/2006. The applicant submitted an ALF application on August 10, 2004, requesting to add a specialty limited mental health (LMH) license. Page 4 of the application indicates that the facility owner is now under the corporate name of Caring Nurses ALF, Inc. Florida Department of State, Division of Corporations lists the date filed for Caring Nurses ALF, Inc. as April 22, 2004. The filing date of this corporation is after the initial submission of the licensure application. TO PAY NOW: PAYMENT SHOULD BE MADE TO: AGENCY FOR HEALTH CARE ADMINISTRATION, ASSISTED LIVING UNIT, 2727 MAHAN DR., TALLAHASSEE, FL. 32308 ALONG WITH A COPY OF THIS NOTICE OF INTENT. Visit AHCA Online ar 2727 Mahan Drive e Mail Stop #30 www fidhe.state fl. us Tallahassee, FL 32308 STATE OF FLORIDA AGENCY FOR HEALTHCARE ADMINISTRATION CARING NURSES ALF, INC., Petitioner, vs. AHCA CASE NO. 2004007746 DOAH CASE NO. 04-3844 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Respondent, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”), by and through its undersigned representatives, and Petitioner, Caring Nurses Assisted Living Facility, Inc. (hereinafter the “Petitioner”), by and through its undersigned representatives, and pursuant to Section 120.57(4), Florida Statutes (2004), each individually, a “party,” and collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Petitioner is an Assisted Living Facility licensed by the Agency pursuant to Chapter 400 Part II, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Petitioner pursuant to Chapter 400, Florida Statues; and WHEREAS, the Agency served Petitioner with a Notice of Intent to Impose Late Fine on August 25, 2004, notifying Petitioner of the Agency’s intent to impose an administrative fine of five thousand dollars ($5, 000.00) for Petitioner’s failure to submit a change of ownership EXHIBIT A ~ tabbles” application to the Agency for a new license at least sixty (60) days before the date of transfer of ownership, in accordance with Section 400.412(1), Florida Statutes; and WHEREAS, Petitioner requested a formal administrative hearing pursuant to Section 120.57(1), Florida Statutes; and WHEREAS, the matter was set for formal hearing in the Division of Administrative Hearings or about January 3, 2005; and WHEREAS, jurisdiction in this matter was relinquished to the Agency from the Division of Administrative Hearings on or about November 30, 2004; WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated hercin are binding findings of the parties. 3. Upon full execution of this Agreement, Petitioner agrees to a withdrawal of its Petition for a Formal Hearing; agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Section 120.57(2), Florida Statutes, a formal proceeding under Section 120.57(1), Florida Statutes, appeals under Section 120.68, Florida Statutes, and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. 4. Upon full execution of this Agreement, Petitioner agrees to pay three thousand seven hundred and fifty dollars ($3,750.00) to the Agency within thirty (30) days of entry of the Final Order. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Flonda. 5. Petitioner admits the allegations set forth in the Notice of Intent to Impose Late Fine. 6. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 7. Each party shall bear its own costs and attorney fees. 8. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 9, Petitioner for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Petitioner or related facilities. 10. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph nine of this Agreement. il. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. Petitioner has the capacity to execute this stipulation and has done so without the advice of counsel. Petitioner understands that she has the ri ght to consult with counsel and has knowingly and freely entered into this stipulation without exercising her right to consult with counsel. Petitioner affirms that Petitioner understands that counsel for the Agency represents solely the Agency and Agency counsel has not provided legal advice to or influenced the Petitioner in her decision to enter into this Agreement. 12. This Agreement contains and incorporates the entire understanding and agreement of the parties. 13. This Agreement supercedes any prior oral or written agreements between the parties. 14. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. 15. All parties agree that a facsimile signature contained herein shall be as valid and binding as an original signature. The Remainder of This Page Intentionally Left Blank AHCA GENERAL COUNSEL PAGE 6/06 a2/15/28285 99:58 7275521448 16. Petitioner’s request for a formal hearing has been relinquished from the Division of Administrative Hearings. However, im the event that this Settlement is not executed, by all parties, and accepted by the Agency. then the Respondent shall have the right to request the Division of Administrative Hearings to reopen the casc. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. “4 Ee Helen Padilla, R.N. Owner/Administrator Caring Nurses ALF, Inc. Agency for Health Care Administration 900 South Highland Avenue 2727 Mahan Drive, MS #9 Clearwater, Florida 33756 Tallahassee, Florida 32308 DATED: LS 0S DATED: Ys 7p Ss OBES : ‘: Wietas Az-7~4General Counsel Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee Florida 32308 DATED: PL ONT JT¥YND CS6O6FFL2L XVA TS+68H GOOS/aT/20 100/TO0

Docket for Case No: 04-003844