STATE OF FLORIDA as *e, & fy AGENCY FOR HEALTH CARE ADMINISTRATION MU 6 é Py STATE OF FLORIDA, AGENCY FOR 40h ‘Sry, 4: 10 HEALTH CARE ADMINISTRATION, Hels Ft Oe “ARTY sue GG XE Petitioner, vs. Case No. 2006002741 MANJO INVESTMENTS, INC., ~ n> d/b/a PALMETTO PLACE, OD le ~ o > CT Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter ““Agency”), by and through the undersigned counsel, and files this Administrative Complaint against MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2005), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of THREE THOUSAND AND NO/100 DOLLARS ($3,000.00), based upon the Respondent being cited with one (1) Class I deficiency pursuant to Section 400.419(2)(b), Florida Statutes (2005), and four (4) repeat Class III deficiencies, pursuant to Section 400.419(2)(c), Florida Statutes (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 400.407, Florida Statutes (2005). 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable statutes, rules, and regulations governing assisted living facilities pursuant to the Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 16-bed assisted living facility located at 5341 Palmetto Road, New Port Richey, Pasco County, Florida 34652, and is licensed by the Agency to operate such assisted living facility (License Number 5630). 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 7. Pursuant to Rule 58A-5.020(2)(c), Florida Administrative Code, all regular and therapeutic menus to be used by an assisted living facility shall be reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or licensed dietitian/nutritionist to ensure the meals are commensurate with the nutritional standards. Such review shall be documented in the assisted living facility’s files and include the signature of the reviewer, registration or license number, and date reviewed, 8. On or about May 25, 2005, the Agency conducted an appraisal survey at Respondent’s assisted living facility (hereinafter ‘“Facility”). Nw 9. Based on interview, observation, and record review during the May 25, 2005, survey, the Agency determined that the Respondent failed to document the date of review of menus used by the Facility. 10. During record review of the Facility menus on May 25, 2005, an Agency surveyor determined that the menus were signed, but not dated, by the registered dietitian. il. | The Respondent was unable to provide any documentation of the date of review of the menus being utilized by the Facility. 12. In an interview conducted on or about May 25, 2005 at approximately 10:00 a.m., the Facility’s administrator confirmed that the menus were not dated and that no other documentation concerning the date of menu review was contained in the Facility’s files. 13. Based upon the above, the Agency determined that the Respondent failed to document the date of review of menus used by the Facility, in violation of Rule 5 8A-5.020(2)(c), Florida Administrative Code. 14. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 15. The Agency cited the Respondent for a Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 16. The Agency provided Respondent with a mandatory correction date of June 25, 2005. 17. The Agency determined that the above-described deficient practice was corrected by August 30, 2005. 18. On or about February 8, 2006, the Agency conducted a biennial survey at the Facility. 19. Based on interview, observation, and record review during the February 8, 2006, survey, the Agency determined that the Respondent failed either to (1) document the date of review of menus used by the Facility, or (2) ensure that the menus used by the Facility are reviewed and/or dated annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or licensed dietitian/nutritionist to ensure the meals are commensurate with the nutritional standards. 20. During the February 8, 2006, survey of the Facility, an Agency surveyor observed menus dated in 2004 posted on a Facility bulletin board located next to the office door. 21. Review of the posted menus revealed a dietitian’s signature, but no date of review. 22, The Administrator confirmed that the posted menus were being utilized by the Facility at the time of the February 8, 2006, survey. 23. The Facility was unable to provide any documentation of a date of review subsequent to 2004 for the menus being utilized by the Facility. 24. Based upon the above, the Agency determined that the Respondent either (1) failed to ensure that the menus used by the Facility were reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or licensed dietitian/nutritionist to ensure the meals are commensurate with the nutritional standards, and/or (2) failed to document the date of review of menus used by the Facility, in violation Rule 58A-5.020(2)(c), Florida Administrative Code. 25. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 26. The Agency cited the Respondent for a repeat Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 27, The Agency provided Respondent with a mandatory correction date of March 8, 2006. 28. Respondent’s failure to (1) ensure that the menus used by the Facility were reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or licensed dietitian/nutritionist to ensure the meals are commensurate with the nutritional standards, and/or (2) document the date of review of menus used by the Facility, in violation Rule 58A-5.020(2)(c), Florida Administrative Code, as set forth in this count, constitutes grounds for the imposition of an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00), pursuant to Section 400.419(2)(c), Florida Statutes (2005). WHEREFORE, the Agency intends to impose an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 400.419(2)(c), Florida Statutes (2005). COUNT I 29. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 30. Pursuant to Rule 58A-5.0182(2)(c), Florida Administrative Code, an assisted living facility is required to post an activities calendar in common a area where residents normally congregate. 31. On or about May 25, 2005, the Agency conducted an appraisal survey at Respondent’s assisted living facility (hereinafter “Facility”). 32. Based upon observation, the Agency determined that the Respondent failed to post the activities calendar in a common area where residents normally congregate in the Facility. 33. During the initial tour of the Facility on or about May 25, 2005, at approximately 9:40 a.m., it was determined that the activities calendar was not posted anywhere in the Facility. 34. Based upon the above, the Agency determined that the Respondent failed to post the activities calendar in a common area where residents normally congregate in the Facility, in violation of Rule 58A-5.0182(2)(c), Florida Administrative Code. 35. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 36. The Agency cited the Respondent for a Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 37. The Agency provided Respondent with a mandatory correction date of June 25, 2005. 38. The Agency determined that the above-described deficient practice was corrected by August 30, 2005. 39. On or about February 8, 2006, the Agency conducted a biennial survey at the Facility. 40. Based on observation and interview, the Agency determined that the Respondent failed to post the activities calendar in a common area where residents normally congregate. 41. Observations during the Facility tour on February 8, 2006, revealed that the January 2006 activities calendar was still posted. 42. Inan interview, the Administrator confirmed that the current (February 2006) activities calendar was not posted in common area where residents normally congregate. 43. Based upon the above, the Agency determined that the Respondent failed to post the activities calendar in a common area where residents normally congregate, in violation of Rule 58A-5.0182(2)(c), Florida Administrative Code. 44, The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 45. The Agency cited the Respondent for a repeat Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 46. The Agency provided the Respondent with a mandatory correction date of June 25, 2005. 47. Respondent’s failure to post the activities calendar in a common area where residents normally congregate, in violation of Rule 58A-5.0182(2)(c), Florida Administrative Code, as set forth in this count, constitutes the grounds for the imposition of an administrative fine in the amount of FIVE HUNDRED AND N0/100 DOLLARS ($500.00), pursuant to Section 400.419(2)(c), Florida Statutes (2005). WHEREFORE, the Agency intends to impose an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 400.419(2)(c), Florida Statutes (2005). COUNT I 48. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 49. Pursuant to Rule 58A-5.019(3)(a), Florida Administrative Code, all assisted living facility staff hired on or after October 1, 1998, to provided personal services to residents must be screened in accordance with Section 400.4174, Florida Statutes, and meet the screening standards of Section 435.03, Florida Statutes. A Level 1 Criminal History Request must be submitted to the Agency within ten (10) days of the employee’s starting work. 50. Pursuant to Section 400.4275(2), Florida Statutes (2005), and Rules 58A- 5.019(3)(b) and 58A-5.024(2)(a)(3), Florida Administrative Code, the results of the employee screening conducted by the Agency shall be maintained in the employee’s personnel file. 51. Onor about October 12, 2005, the Agency conducted a complaint investigation (CCR# 2005008635) at Respondent’s assisted living facility (hereinafter “Facility”). 52. Based on record review and interview, the Agency determined that the Respondent failed to ensure that personnel records for one (1) of one (1) employee (Staff #1) record reviewed contained documentation of compliance with level 1 background screening. 53. Interview, observation, and/or record review revealed that Staff #1 had been an employee of the Facility for ten (10) or more days. 54. Interview, observation, and/or record review revealed that Staff #1 provided personal services to residents of the Facility. 55. Review of Staff #1’s personnel file revealed neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 56. In an interview conducted on or about October 12, 2005, at approximately 9:30 a.m., the caregiver in charge indicated that a background screening had been requested for Staff #1, but that the results had not been received. 57. Based upon the above, the Agency determined that the Respondent failed to ensure that personnel records for one (1) of one (1) employee (Staff #1) record reviewed contained documentation of compliance with level 1 background screening, in violation of Section 400.4275(2), Florida Statutes (2005), and Rules 58A-5.019(3)(b) and 58A- 5.024(2)(a)(3), Florida Administrative Code. 58. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 59. The Agency cited the Respondent for a Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 60. The Agency provided Respondent with a mandatory correction date of November 12, 2005. 61. The Agency determined that above-described deficient practice was corrected by November 16, 2005. 62. On or about February 8, 2006, the Agency conducted a biennial survey at the Facility. 63. Based on record review and interview, the Agency determined that the Respondent failed to provide documentation of compliance with level 1 background screening for four (4) of five (5) staff members (Staff #1, #2, #4, and #5). 64, Interview, observation, and/or record review revealed that Staff #1 had been an employee of the Facility for ten (10) or more days. 65. Interview, observation, and/or record review revealed that Staff #1 provided personal services to residents of the Facility. 66. Review of Staff #1’s personnel file revealed neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 67. Interview, observation, and/or record review revealed that Staff #2 had been an employee of the Facility for ten (10) or more days. 68. Interview, observation, and/or record review revealed that Staff #2 provided personal services to residents of the Facility. 69. Review of Staff #2’s personnel file revealed neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 70. Interview, observation, and/or record review revealed that Staff #4 had been an employee of the Facility for ten (10) or more days. 71. Interview, observation, and/or record review revealed that Staff #4 provided personal services to residents of the Facility. 10 72. Review of Staff #4’s personnel file revealed neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 73. Interview, observation, and/or record review revealed that Staff #5 had been an employee of the Facility for ten (10) or more days. 74, Interview, observation, and/or record review revealed that Staff #5 provided personal services to residents of the Facility. 75. Review of Staff #5’s personnel file revealed neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 76. During the exit conference on or about February 8, 2006, at approximately 3:30 p.m., the Facility’s administrator confirmed that personnel files for Staff #1, 2, #4, and #5 contained neither the results of a completed level 1 background screening, nor any documentation indicating that a request for such screening had been made to the Agency. 77. Based upon the above, the Agency determined that the Respondent failed to ensure that personnel records for one (1) of one (1) employee (Staff #1) record reviewed contained documentation of compliance with level 1 background screening, in violation of Section 400.4275(2), Florida Statutes (2005), and Rules 58A-5.019(3)(b) and 58A- 5.024(2)(a)(3), Florida Administrative Code. 78. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. il 79. The Agency cited the Respondent for a repeat Class II deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 80. The Agency provided Respondent with a mandatory correction date of March 8, 2006. 81. The Respondent’s failure to ensure that personnel records contained documentation of compliance with level 1 background screening, in violation of Section 400.4275(2), Florida Statutes (2005), and Rules 58A-5.019(3)(b) and 58A-5.024(2)(a)(3), Florida Administrative Code, as set forth in this count, constitutes the grounds for the imposition of an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00), pursuant to Section 400.419(2)(c), Florida Statutes (2005). WHEREFORE, the Agency intends to impose an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 400.419(2)(c), Florida Statutes (2005). COUNT IV 82. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 83. Pursuant to Rule S8A-5.019(4)(a)(1), Florida Administrative Code, an assisted living facility with a census of between sixteen (16) and twenty-five (25) residents shall maintain a minimum of two hundred fifty-three (253) staff hours per week. 84. On or about October 12, 2005, the Agency conducted a complaint investigation (CCR# 2005008635) at Respondent’s assisted living facility (hereinafter “Facility”). 85. At the time of the October 12, 2005, survey, the census at the Facility was sixteen (16) residents. Accordingly, the Respondent was required to maintain a minimum of two hundred fifty-three (253) staff hours per week. 86. Based on record review and interview, the Agency determined that the Respondent failed to maintain the minimum two hundred fifty-three (253) staff hours per week. 87. Record review during the October 12, 2005, survey revealed that the Respondent does not maintain a written work schedule for Facility staff. 88. In an interview conducted on or about October 12, 2005, at approximately 9:30 p-m., the caregiver in charge confirmed that there is only one (1) direct care staff member on duty twenty-four (24) hours per day, seven (7) days per week. Even if such direct care staff member were awake and available to provide care twenty-four (24) hours per day and seven (7) days per week that would result in total staff hours of one hundred sixty-eight (168). Such amount total falls below the minimum two hundred fifty-three (253) staff hours per week required for a census of sixteen (16) residents. 89. Based upon the above, the Agency determined that the Respondent failed to maintain the minimum two hundred fifty-three (253) staff hours per week required for a an assisted living facility with a census of sixteen (16) residents, in violation of Rule 58A- 5.019(4)(a)(1), Florida Administrative Code. 90. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 91. The Agency cited the Respondent for a Class III deficiency in accordance with Section 400.419(2)(c), Florida Statutes (2005). 92. The Agency provided Respondent with a mandatory correction date of November 12, 2005. 13 93. The Agency determined that the above-described deficient practice was corrected by November 16, 2005. 94. On or about February 8, 2006, the Agency conducted a biennial survey at the Facility. 95. At the time of the February 8, 2006, survey, the Facility staff claimed to have a current census of fourteen (14) residents. However, record review and interview revealed that an additional three (3) residents were receiving services at the Facility. 96. These three (3) additional residents were documented as receiving medications on the Facility’s Medication Observation Record at 8:00 a.m. and 8:00 p.m. 97. In addition, in an interview conducted on or about February 10, 2006, at approximately 11:00 a.m., the case managing agency for these three (3) additional residents indicated such agency had indeed placed these residents at the Facility, and that such residents were receiving care there. 98. Accordingly, at the time of the February 8, 2006, survey, the Facility had a current census of seventeen (17) residents. Therefore, the Respondent was required to maintain a minimum of two hundred fifty-three (253) staff hours per week. 99. _ Based on record review and interview, the Agency determined that the Respondent failed to maintain the minimum two hundred fifty-three (253) staff hours per week. 100. A review of the Facility’s most recent staff schedule revealed that the total scheduled number of staff hours was two hundred twenty-eight (228). 101. Based upon the above, the Agency determined that the Respondent failed to maintain the minimum two hundred fifty-three (253) staff hours per week required for a an 14 assisted living facility with a census of seventeen (17) residents, in violation of Rule 58A- 5.019(4)(a)(1), Florida Administrative Code. 102. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents and indirectly or potentially threatened the health, safety, or security of the Facility residents. 103. The Agency cited the Respondent for a repeat Class IIT deficiency in accordance with Section 400.419(2)(b), Florida Statutes (2005). 104. The Agency provided Respondent with a mandatory correction date of March 8, 2006. 10S. The Respondents repeated failure to maintain the minimum two hundred fifty- three (253) staff hours per week required for a an assisted living facility with a census of between sixteen (16) and twenty-five (25) residents, as set forth in this count, constitutes the grounds for the imposition of an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00), pursuant to Section 400.419(2)(c), Florida Statutes (2005). WHEREFORE, the Agency intends to impose an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 400.419(2)(c), Florida Statutes (2005). COUNT V 106. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 107. Pursuant to Rule 58A-5.0182(1), Florida Administrative Code, assisted living facilities shall offer personal supervision, as appropriate for each resident. 108. On or about February 8, 2006; the Agency conducted a biennial survey at i5 Respondent’s assisted living facility (hereinafter “Facility”). 109. Based on observation, record review and interview, the Agency determined that the Respondent, by failing to maintain adequate staffing levels, was unable to provide appropriate supervision for six (6) of six (6) sampled residents. 110. Upon entrance to the Facility on February 8, 2006, at approximately 9:40 a.m., in response to an inquiry from an Agency surveyor as to where Facility staff could be located, a resident went next door to wake the Facility’s administrator (hereinafter “Administrator’). Observation revealed no other Facility staff members on the premises at such time. 111. In interviews conducted during the February 8, 2006, survey, Facility residents indicated that the Administrator lives next door and usually sleeps until noontime. 112. After requesting to review the Facility staff schedule for February 2006, Agency surveyors were directed to the Facility bulletin board, where only the January 2006 staff schedule was posted. . 113. The Administrator was unaware that there no written February 2006 staff schedule was posted. 114, _A different handwritten schedule posted on the Facility bulletin board indicated that the Facility cook (hereinafter “Cook”) worked from 7:00 a.m. until 7:00 p.m., Monday through Friday. 115. In an interview conducted on or about February 8, 2006, at approximately 10:30 a.m., the Cook indicated that he is at the Facility only to cook, serve and clean up at mealtimes (breakfast, lunch and dinner). The Cook further indicated that between mealtimes he is not present at the Facility. 16 116. The handwritten schedule also indicated that another facility staff member was scheduled to work during the day on February 8, 2006. Such staff member was not present at the Facility at the outset of the survey, but did briefly stop by the F acility while on her way to a family member’s doctor appointment. 117. In an interview conducted on or about February 8, 2006, at approximately 11:30 a.m., the Administrator indicated that she is not always on the premises during her shifts as she goes next door to her house. 118. During times when no scheduled Facility staff are present at the Facility and the Administrator is not on the premises because she at her residence next door, all residents at this Facility receive inadequate personal supervision. 119. Observation, and subsequent record review and interview, revealed one such instance of inadequate personal supervision as follows: a. Resident #3 was admitted to the Facility on April 9, 2004 with diagnoses including Schizo-Paranoia. b. A review of the Resident #3’s record revealed progress notes documenting false “911” calls, with a January 23, 2006, entry indicating stating that Resident #3 requires supervision when nearby a telephone. Cc. In an interview conducted on or about February 10, 2006, at approximately 12:00 p.m., Resident #3°s case manager indicated that that resident is unable to appropriately complete activities of daily of living on his/her own due to poor thought process and cognitive performance. d. Upon entrance to the Facility at approximately 9:40 a.m. on February 8, 2006, Resident #3 was observed calling "911" on the Facility telephone. e. When an Agency surveyor asked where Facility staff could be found, a different resident went next door to wake the Facility’s administrator (hereinafter “Administrator”). Observation revealed no other Facility staff on the premises at such time. 17 120. In an interview conducted on or about February 8, 2006, at approximately 10:00 a.m., the emergency medical technicians (hereinafter “EMTs”) who responded to Resident #3’s “911” call indicated that they respond to Resident #3’s calls at this Facility about one (1) time per week. In addition, the EMTs indicated that they occasionally receive and respond to calls from other residents as well. 121, The EMTs further indicated that many times when they arrive at the Facility, there are no on-duty staff members present on the premises. 122, The lack of Facility staff on premises (1) to care for and tend to the scheduled and/or unscheduled needs of Facility residents, and/or (2) to provide personal supervision, as appropriate for each resident presents a direct threat to the physical or emotional health, safety, or security of the unsupervised Facility residents. 123. Based upon the above, the Agency determined that the Respondent failed to offer personal supervision, as appropriate for each resident, in violation of Rule 58A-5.0182(1), Florida Administrative Code. 124. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents, 125, The Agency cited the Respondent for a Class II deficiency in accordance with Section 400.419(2)(b), Florida Statutes (2005). 126. The Agency provided Respondent with a mandatory correction date of February 22, 2006. 127. Respondent’s failure to offer personal supervision, as appropriate for each resident, in violation of Rule 58A-5.0182(1), Florida Administrative Code, as set forth in this 18 count, constitutes grounds for the imposition of an administrative fine in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1000.00), pursuant to Section 400.419(2)(b), Florida Statutes (2005). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1000.00), pursuant to Section 400.419(2)(b), Florida Statutes (2005). Respectfully submitted this fe day of June 2006. Brian T. Mulligan Fla. Bar. No. 0676543 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330L St. Petersburg, Florida 33701 Respondent 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 Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida 32308. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8597 on June Vial , 2006 to: Amanda N. Mark, Registered Agent, Palmetto Place, 5335 Palmetto Road, New Port Richey, Florida 34652 and by U.S. Mail to: Amanda N. Mark, Administrator, Palmetto Place, 5341 Palmetto Road, New Port Richey, Florida 34652. AE an T. Mulligan 19 Copies furnished to: Amanda N. Mark Registered Agent Palmetto Place 5335 Palmetto Road New Port Richey, Florida 34652 (U.S. Certified Mail) Amanda N. Mark Administrator Palmetto Place 5341 Palmetto Road New Port Richey, Florida 34652 (U.S. Mail) Brian T. Mulligan. Agency for Health Care Admin. 525 Mirror Lake Drive, 330L St. Petersburg, Florida 33701 (nteroffice) 20

Docket for Case No: 06-002387