EXHIBIT A STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No, 2004009582 w t GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, fp ye Cue Yeo] Respondent. - ADMINISTRATIVE COMPLAINT. COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “Petitioner”), by and through the undersigned counsel, and files this Administrative Complaint against GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, hereinafter referred to as “Respondent,” pursuant to §§120.569 and 120.57, Fla. Stat. (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines totaling $49,500. The Respondent was cited for violations during a complaint investigation by AHCA, conducted on March 23, 2004. JURISDICTION AND VENUE 2. AHCA has jurisdiction over the Respondent, pursuant to §§ 120.569 and 120.57, Fla. Stat. (2004). 3. Venue is proper in Bay County, FL, pursuant to Rule 28-106.207, Fla. Admin. Code. Respondent was, at all times material hereto, located in and doing business in Bay County, Florida. PARTIES 4. Pursuant to Chapter 400, Part IM, Fla. Stat., and Chapter 58A-5, Fla. Admin. Code, AHCA is the licensing and enforcing authority with regard to assisted living facility laws and tules. 5. The Respondent is an assisted living facility located at 3409 West 19" Street, Panama City, Flonda 32405. The Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part I, Fla. Stat., and Rule 58A-5, Fla. Admin. Code, having been issued license number 10146. OUNT I THE FACILITY DID NOT PROVIDE A REFUND TO TWO RESIDENTS OR RESPONSIBLE PARTIES WITHIN 45 DAYS AFTER THE DEATH OF THE RESIDENTS. $400.424(3)(a), Fla. Stat. 6. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. On March 22, 2004, a complaint investigation was initiated at the Respondent’s facility. At that time, based on record review and staff interview, the facility was cited for failing to provide statutorily mandated refunds to the family or the responsible party within 45 days for two of four sampled residents (patients #3 and 4) after the death of the residents. On September 21, 2004 a follow up survey to the complaint investigation was conducted at Respondent’s facility. At that time, based on record review and staff interview, the Respondent was again cited for failing to provide statutorily mandated refunds to the family or the responsible party within 45 days for two of four sampled residents (patients #3 and 4) after the death of the residents. 8. This failure was based upon the following facts: A review of the closed records for residents #3 and #4 was conducted on 9/21/04 and revealed the following: Residents #3 and #4 both had signed contracts for $750.00 per month, with an addendum that was signed by both residents, their power of attomey and the facilities administrator and notarized bya notary public. The addendum stated that the Health Care Surrogates will pay two years upfront for a total of $36,000.00. The addendum also stated that should both of the residents pass away before the 30° day of November 2004 that the facility shall pay the Health Care Surrogates any remaining prepaid fees at a rate of $1,500.00 per month until the remaining prepaid fees are returned in full. The addendum also stated that the two residents monthly rate will be $1,500.00 per month and shall not increase for the remainder of their lives. There were no other addendums ox updated contracts in the record stating that the rates had been increased or that there were any additional charges that were agreed upon. The record showed that resident 43 passed away (12/24/03) after 8 months into the contract and resident #4 passed away (07/20/03) after 13 months iuto the contract. According to the contract and the addendum to the contract, the facility owed the Health Care Surrogates for the final 11 months of the 24 month contract at $1 ,500.00 per month for a total of $16,500.00. 9. The Respondent’s failure to refund the residents’ monics within in 45 days of their death is in violation of §400.424(3)(a), Fla. Stat. (2004), reading in pertinent part as follows: (T]he facility shall provide a refund to the resident or responsible party within 45 days after the transfer, discharge, or death of the resident. The agency shall impose a fine upon a facility that fails to comply with the refund provisions of this paragraph, which fine shall be equal to three times thc amount due the resident. One-half the fine shall be remitted to the resident or his or her estate, and the other half of the fine to the Health Care Trust Fund to be used for the purpose specified in s. 400.418 (emphasis supplied). The Respondent’s failure to refund the residents’ monies. within 45 days of their death warrants the imposition of a fine equaling three times the amounts due the residents, or $49,500. WHEREFORE, AHCA demands the following relief: 1. Entry of factual and legal findings as set forth in the allegations of Count | of this Administrative Complaint; 2. Imposition of fines totaling $49,500, including an amount equal to three times the refund due, pursuant to §400.424(3)(a), Fla. Stat. (2004), which shall be divided one-half to the estates of patients #3 and 4, and one-half to the Health Care Trust Fund. 3, Any other relief this Court finds necessary and proper. Submitted on this 10th day of November 2004. Agency for Health Care Administration 2727 Mahan Dr., Bldg 3, MSC 3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 413-9313 (fax) NOTICE The Respondent, GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Fla. Stat. (2003). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3,Tallahassee, Florida, 32308; Attention: Agency Clerk. The Respondent is further notified, if the request for hearing is not received by the Agency for Health Care Administration within twenty-one (21) days of receipt of this Administrative Complaint, a Final Order will be entered. CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested, Receipt No. 7003 1010 0000 9716 1264 to Jane Adele Jones, Administrator, Gold Key Development, Inc., d/b/a Carriage Inn; 3409 West 19% Street; Panama City, Florida 32405. Submitted on this 10th day of November 2004.

Docket for Case No: 04-004637