O¥-3935, TILED STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION? JULIO PH 2: 45 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2008004204 Return Receipt Requested: v. 7004 2890 0000 5525 8504 7004 2890 0000 5525 8511 REVIVAL HOME, INC. d/b/a REVIVAL HOME, INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Revival Home, Inc. d/b/a Revival Home, Inc. (hereinafter “Revival Home, Inc.”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2007), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and Chapter 28-106, Florida Administrative Code (2007). 3. Venue lies in Miami-Dade County pursuant to Section 120.57, Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code (2007). 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 429, Part I, Florida Statutes (2007), and Chapter 58A-5 Florida Administrative Code (2007). 5. Revival Home, Inc. operates a 72-bed assisted living facility located at 68 West 7 Street, Hialeah, Florida 33010. Revival Home, Inc. is licensed as an assisted living facility under license number 9109. Revival Home, Inc. 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 REVIVAL HOME, INC. FAILED TO PROVIDE SUPERVISION AS APPROPRIATE FOR EACH RESIDENT. RULE 58A-5.0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5). as if fully set forth herein. 7. Revival Home, Inc. was cited with one (1) Class II deficiency due to a complaint investigation survey that was conducted on February 27, 2008. 8. A complaint investigation survey was conducted on February 27, 2008. Based on record review and interview, it was determined that the facility failed to offer personal supervision as appropriate for each resident, including general awareness of the resident's whereabouts for 1 of 3 sampled residents. The findings include the following. 9. After record review of the resident #1, it was noted that the resident had a diagnostic of Acute Psychosis and the physician had requested a daily oversight of the resident, for example, observing resident's well being and whereabouts. 10. Resident #1 left the facility on January 25 2008 and return on January 28, 2008. The facility did not know where the resident was and the resident never received her/his medications during that time. 11. The resident left the facility again on February 21, 2008 and has not returned to facility as of the date of the survey, February 27, 2008. 12. Interview with the administrator on February 27, 2008 at 11:00 a.m. revealed that there was no system in place in the facility to monitor residents whereabouts, only if a resident would not show up for medications, then they would check if resident is in the facility or not. 13. The administrator also stated that it is not the first time that resident #1 leaves facility without telling anyone and stays away for two (2) days. 14. An interview was also conducted with another resident who revealed that resident #1 left the facility often and came back after one or two days. 15. Based on the foregoing facts, Revival Home, Inc. violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. 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 Revival Home, Inc. on Count I. 2. Assess an administrative fine of $1,000.00 against Revival Home, Inc. 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 (2007). 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 the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE 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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER J hc €2 Whewe ue ourdes A. Naranjo, Esq Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. Miami, Copies furnished to: R. Steve Emling Field Office Manager Agency for Health Care Administration 8355 N. W. 53°* Street Miami, Florida 33166 (Interoffice Mail) 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) 52 Terrace - #103 Florida 33166 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 Rayza Vazquez, Administrator, Revival Home, Inc., 68 West 7 Street, Hialeah, Florida 33010; Jorge Benito, Registered Agent, 1316 Alhambra Circle, Coral Gables, Florida 33134 on this 6S “day of , 2008. free, (enc tet py rdes A. Naranjo, Esq. ¢ ™ Complete items 1, 2,.and 3. Also complete i, _ item 4 if Restricted Delivery is desired... | 1. Article Addressed to: ery Banks Dia AChambacs Cts Cnn Wath. © lenrides 535u Postage | $ Certified Fee rn Receipt Fee cendaraement Required) ed Delivery Fee (Cusorsement Required} otal Postage & Fees 7oo04 2890 ooo0 5525 8511 (Transfer from service label) i, eben PS Form 3811, August 2001 AS Forti 3o00, JUN 20RS ase @ Print your name and address on the reverse 3.. Service Type COMPLETE THIS SECTION ON DELIVERY D. Is défivery address different from item 1? (1 Yes ~IEYES, enter delivery address below: . [1 No Cl Certified Mail 1) Express Mail ©] Registered +. C] Return Receipt fot Merchandise Ol insured Mail 1 C.0.D. 7004 2850 O000 5525 aSll Domestic Return Receipt astricted Delivery? (Extra Fee) O Yes ae 4) ~ 7 2ACPRI-03-Z-0985 Gln Com pay :

Docket for Case No: 08-003335