@6-18-'@8 12:11 FROM-A.H.C.A 7279921446 T-584 P@G6/@51 F-856 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR . a OT HEALTH CARE ADMINISTRATION, a & Ale { 5 Petitioner, vs. Case No. 2008005952 MUNNE CENTER, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against MUNNE CENTER, INC., (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility pursuant to §408.815(1)(a), Florida Statutes (2007). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes (2006). 2, Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living @6-18-'@8 12:12 FROM-A.H.C.A 7279921440 7-584 P@G7/051 F-856 facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code. 4. Respondent operates a 160-bed assisted living facility located at 17250 SW 137" Avenue, Miami, Florida 33177, and is licensed as an assisted living facility with limited nursing services and limited mental health, license number 9446. 5. Respondent was at ali 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 (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest...(a) False representation of a material fact in the license application or omission of any material fact from the application. Section 408.815(1)(a), Florida Statutes (2007). 8. That on or about September 6, 2005, Respondent was issued a Standard license with Limited Mental Health and Limited Nursing Services based upon its Assisted Living Facilites (ALF) License Application (Hereinafter “2005 Application”) submitted on or about June 2, 2005, a copy of which is attached hereto and incorporated herein by reference as Exhibit “A.” 9. That the 2005 Application lists as the ownership of the shares of the Respondent ) corporate entity as Ray Gonzalez, Rene Gonzalez, and Alexis Agreda owning thirty three percent (33%), thirty three percent (33%), and thirty four percent (34%) of the corporate entity respectively. we @6-18-'@8 12:12 FROM-A.H.C.A 7275521446 T-584 P@08/051 F-@56 10. That on or about August 18, 2005, Alejandro Perez purchased the entire outstanding shares of the stock of the Respondent Corporation. 11. Correspondence to this effect was directed to the Petitioner on or about September 23, 2005. 12. That the Respondent filed an Assisted Living Facilities (ALF) License Application (Hereinafter “2007 Application”) seeking the renewal of its license as an assisted living facility on or about June 28, 2007, a copy of which is attached hereto and incorporated herein by reference as Exhibit “B”. 13. That the 2007 Application lists as the ownership of the shares of the Respondent corporate entity as Ysel Hernandez owning one hundred percent (100%) of the corporate entity. 14. That upon information and belief, Ysel Hernandez did not own any shares, stock, or other interest in the Respondent corporation at the time of the 2007 Application. 15. That the 2007 Application lists as the ownership of the shares of the Respondent’s management company as Ysel Hernandez owning one hundred percent (100%) of the management company. 16. That upon information and belief, Ysel Hernandez did not own any shares, stock, or other interest in a management company which provided services to Respondent corporation or its licensed facility at the time of the 2007 Application. 17. That Respondent has continuously operated as an assisted living facility since at least June 2005 to the date of this Complaint. 18. That Respondent in its 2007 Application listed the one-hundred percent (100%) _ ownership of the outstanding shares or stock of the Respondent corporate licensee as Ysel Hermandez, @6-18-'@8 12:42 FROM-A.H.C.A 7275521446 T-584 P@09/051 F-@56 19. That the controlling interest of the entity is a disclosure required by law. See, Section 408.806(1)(a), Florida Statutes (2007). 20. That the controlling interest of a corporate licensee is a material fact. 21. — That acts or omissions of controlling interests are grounds for the denial of an application or revocation of a license as an assisted living facility. See, Sections 429.14(g), 408.815(2), Florida Statutes (2007). 22. That Respondent’s falsely indicated that Ysel Hernandez owned the totality of the business interest in the Respondent corporation and or omitted the true controlling interest and owner of the Respondent corporation’s corpus as that of Alejandro Perez in Respondent’s 2007 Application. | 23. That Respondent’s false disclosure of the controlling interest and ownership of the corpus of the Respondent’s entity in accord with the statutory mandates subjects the licensee to administrative penalties as provided by law. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ Section 408.815(1)(a), Florida Statutes (2007). Respectfully submitted this day of May, 2008. . Walsh HL, Esq. Fig Bar. No. 566365 ‘ounsel for Petitioner Agency for Health Care Administration $25 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) @6-18-'@8 12:12 FROM-A.H.C.A 7275521440 T-584 P@10/@51 F-@56 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120,569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 43,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. 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 1 HEREBY CERTIFY that a true and correct copy of the foregoing hasjeen served by U.S. Certified Mail, Return Receipt No. 7007 1490 0001 6979 0994 on May , 2008 to Sean M. Ellsworth, Esq, Counsel for Respondent, Munne Center Inc., 404 Washington Avenue, Suite 750, Miami, Florida 33139, and regular U.S. Mail to Anthony C. Vitale, Esq., Counsel for Respondent, 2333 Brickell Avenue, Suite A-1, Miami, FL 33129. Copies furnished to: Sean M. Ellsworth, Esq, Anthony C. Vitale, Esq. Counsel for Respondent 2333 Brickell Avenue Munne Center Inc. : Suite A-1 404 Washington Ave., Suite 750 Miami, FL 33129 Miami, Florida 33139 (U.S. Mail) (U.S. Certified Mail) Robert Emling Thomas J. Walsh II Field Office Manager Senior Attomey Agency for Health Care Admin, Agency for Health Care Admin. 8355 NW 53” Street, 1 Floor, #100 Miami, Florida 33166 (U.S. Mail 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) @6-18-'@8 12:12 FROM-A.H.C.A 7275521444 7-584. P@11/051 F-@56 eo State of Florida Agency for Health Care Administration ° Assisted Living Unit, Division of Health Quality Assurande 2127 Mahan Drive, Tallahassee, Florida 32308-5403 Telephone: 850-487-2515 * Fax: 850-410- 1476 ahca.myflorida.com. Assisted Living Facilities (ALF) License Application nn en Please type or print in ink. __ G be) 005 a ee eis athestse co Peed erie cn ot nt rr @. Miunne Cerber (S08 859 aFOR — ASAOREA runner sie Name of Facility : Telephone # FAX # E-Mail Address ©- Ory IN250 2.5 1257 Avenue Mianni _ Dace 2209 Facility Street Address City County Zip Code 1250 02 (O77 Avenue. Mian SII Mailing Address City Zip Code { |] Facility Name Change: Facility Name as Currently Licensed we Type of Application: [ ] Initial Application { .] Bed Increase/Decrease [7 Renewa! Application [ ] Add Specialty License { 1. Change of Ownership: — Date Ownership To Be Transferred Type of License: [©T Standard License [ \¥Ljmited Nursing Services (LNS) [ =T Limited Mental Health (LMH) { ] Extended Congregate Care (ECC) as HICA Form 3110-1008, August 2003 . @6-18-'@8 12:12 FROM-A.H.C.A 7275521448 T-584 P@12/051 F-@56 Enter the Standard License Fee: (1) $_ 34 Enter the number of beds (each bed must be designated as either private pay or OSS): (a) Private Pay Beds to be licensed (b) OSS Beds to be licensed _1GO_. (c) Total Number of Beds to be licensed (private pay + OS$3) Wed (d) Multiply the number of private pay beds by the private pay bed fee and enter here: (2) $_ "Hf this is a license renewal, what was the average number of private pay residents (rather than OSS residents) per month housed at the facility during the last license period? | FE this is more than the number of private pay beds designated on your current license multiply the difference by the bed fee and enter here. , .- 3) $_ = If applying for an LNS license, enter the LNS license fee: (4) $ 267 Multiply the total number of facility beds on line 2,(c) by the ros) LNS bed fee: ; (5) $_\& If applying for an ECC license, enter the ECC license fee: (6) $___=— Multiply the total number of facility beds on line 2.(c) by the _ ECC bed fee: (7) $_____—. as) Add the amounts on lines (1), (2), 3), (4), (5), (6) and (7) and enter here: (8) $ 180" IF this is a renewal application mailed less than 90 days prior to license ; expiration, divide the amount on line (8) by two and enter the total here: (9) $ Add lines (8) and (9) and enter here, This is your total fee. (10) $ 7180, - — . = 77 = a AS Tf applying for an LS or ECC license, has the facility maintained a standard license for the past two calendar years, or since initially licensed if licensed less than two years? 7 Yes __ No. . If applying for an LNSor ECC license, has the facility been sanctioned during the past two calendar 2 years __ Yes lo. if applying for an ECG licgise, list the total number of ECC beds requested: N Identify the b iz, ain, oor, and rooms designated for ECC services: ’ . @6-18-"@8 12:12 FROM-A.H.C.A 7275521440 T-584 P@13/051 F-@56 If applying for a LMH license ages the facility currently hold a Standard license and have no uncorrected deficiencies? «Ye: No. s ‘If applying for a LMH license, the administrator and manager, direct care staff, and staff whose duties require daily interaction with mental ‘health residents shalt complete required Department of Children and Family Services mental health training. This training shall be completed within 6 months of receiving 4 LMH license, or within 6 months of employment in a facility with a LMH license. Jf the facility currently holds a Standard license, and this application is only to add an LNS or ECC specialty license between biennial license renewal periods: 1. If applying for an LNS license, enter the prorated license and bed fees: $__ = 2, If applying for an BCC license, enter the prorated license fee: $ = If this application is only to request an increase or decrease in the number of licensed beds (not for an initial, renewal or change of ownership) please complete this section. rw nr Yo Total number of currently licensed ALF beds: |GO_. 4 f\ mar Total number of beds requested to be: __~ Increased “> Decreased, ; Of the total number of beds increased/decreased, how many are: : ber Private Pay Beds: . OSS Designated Beds: ECC Beds If the whole facility is not licensed as ECC, identify the location or section where additional ECC beds will be located: . If applying for an increase in the number of private pay beds, multiply the standard bed fee by the number of private pay beds added and enter here: $0 If your facility also holds an LNS license, multiply the LNS bed fee by the : total number of beds added and enter here: $e If your facility also holds an ECC license, multiply the ECC bed fee by the total number of beds added and enter here: $e REC AHCA Form 3110-1008, August 2003 “ "JUN Oy . 3 @6-18-'@8 12:12 FROM-A.H.C.A 7279521448 T-584 P14/851 F-856 ’ Applicant is a(n): { ] Individual(s} { ) Limited Partnership { ] General Partnership [ Corporation [ ] Other (Specify) If the applicant is a limited partnership or corporation, list the name, document number, and Federal : i number registered with the Florida Department of State, Division of Corporations: gy Nun @. rs ey of limited reper M} lary . Fu. Beh ws) 7 Address) ONO, OROOO'N_O)] BLO | (Document number) (Federal Employer Tdentification Number) Ifa limited partnership or corporation, you may attach a copy of the current “Certificate of Status” issued by the Department of State, Division of Corporations. Is the corporation For Profit? ___ Not for Profit? Are the property and building(s) Owned by the applicant? ___ Leased orrented? If leased or rented, who is the property owner(s)? : Munnt. antes, Tine. i280 22 139 Aw. Miarn! PL gos aeroey . Name Address City/State/Zip’ _ Telephone # Is the facility to be managed by someone other than the applicant? Eee es__ No. If yes, provide the ame Age tte qnanay ent company or individual: (308 _ Rows, reir ree Galis gb an le) A. Miami, Pi Zen 25.9 City/State/Zip Telephone # Fama. ILS R Bo yy Lanz “NACo, FU -BeaBe (Sos) ASE2TI72 You must ornplete the information below regarding the person(s) who has aos) for the facility's financial operation. Ki2 eck Wilus~ gol Name Dateof Birth 3a >) 72a Oo NW Micmat Pe 251ye (o-43024 Mailing Address CioiSaty Telephone # RECENE; ALUN JUN 0 2 2005 ACA Form 31101008 ECDs COMPLE ‘ "4 @6-18-'@8 12:12 FROM-A.H.C.A 72755214468 T-584 P@15/@51 F-856 Complete the following information on each corporate officer, director, individual owner, and partner. Attach additional pages, if necessary. If the applicantiowner is a corporation, complete items 1 thru 7 as applicable. xi Apreds pikes (60°) (dho~ Fol oS Corporate President DOB Telephone # y 7228S Sud “Teo Airs 21 oe Mailing Address City = 2 “WAL Grae. Slane wna aoa ie. iN Corporate Vice-President . Telephone # a0 Bul suo lan Ave Mtv Fe sar bh Mailing Address City State Zip {\° Alexie Rareda Lali WS" (30s) Gul -@o94 ® Corporate Sec: DOB Telephone # 2AaS AD We St Miami Pu. soles Mailing Address City : State . Zip slia2lino _ ¢ 2\0- BUG Rs Ray Gi 2 nN te Treasurer DOB Telephone # 1233 sw ay Sst Milani FU ko iol Mailing Address _ City State Zip 5. Director DOB Telephone # Mailing Address City State Zip 6. : nr _ Director . DOB Telephone # A LR Mailing Address City State Zip 7. : Director DOB Telephone # Mailing Address City State Zip AHA Form 3110-1008, August 2003 rae @6-18-'@8 12:13 FROM-A.H.C.A 7275521448 T-584 P@16/@51 F-@56 If the applicant/owner is an individual(s), complete items 8 thru 11 as applicable. DOB City DOB City DOB City Telephone # State Zip Telephone # _ State Zip Telephone # State _ Zip Telephone # i City State Zip If the applicant/owner is a general or limited partnership, or other type of ownership, complete DOB City DOB Individual Owner Mailing Address 9 7 : Individual Owner Mailing Address 10, Individual Owner Mailing Address 11. Individual Owner Mailing Address items 12 thru 14 as applicable. 1 _ __ : Partner Other (specify): Mailing Address 13, : Partner Other (specify): ” Mailing Address 14, Partner Other (specify): : Mailing, Add Pig JUN 02 2005 _ apy AHCA Form 3110-1008, August 2003 COPE Neee City Telephone # State 2ip Telephone # State 2p Telephone # State Zip @6-18-'@8 12:13 FROM-A.H.C.A 7275521440 T-584 P@17/051 F-@56 Corporations Only: Enter the name(s) and address(es) of each person having at least 25% ownership - interest in the corporation which owns the ALF business (attach an addendum to the application, if necessary). If no person owns at least 5% of the corporation, please enter not applicable. Name Address City/State/Zip Percent of Ownership 1392 e0Ry St Mien FL eS Boa Ron, Qontaie_ pul ao 194 Ave Miani EL. BAY BD dA iS s wok Ulan FL. BBINS ¢ D ae List the name(s) of any facility or other entity licensed by this state or another state to provide health or residential care with which the administrator or any person listed in this section has been affiliated through ownership or employment within the last 5 years. [Attach additional sheets if necessary.] Name & Type of Facility/Entity: Perraiesance, Garcons ACR Address: WSUS _ VS WA Averyic. _. Dates of Affiliation: Ore S¢ ~T__ Employee? 25% or greater ownership interest 7 Yes?____ No? Owner? If the facility or other entity closed or ceased to operate due to financial problems; had a receiver appointed; had its license denied, suspended or revoked; was subject to a moratorium on admissions; or had an injunctive proceeding initiated against it, please provide a detailed description and explanation of the occurrence. [Attach additional sheets if necessary.] Adverse Action(s): Yes? "No? If yes, description, explanation, and date(s) of occurrence Does any owner, partner/associate/firm member, officer, or director have at least a 5% ownership interest in any professional service, firm, associguion, partnership, or corporation providing goods, leases, or services to the facility? __ Yes ¢“ No. If yes, list the name and address of the professional service, firm, association, partnership, or corporation. [Attach additional sheets if necessary.] Name of Business: Address: Nature of Business Relationship: U% ee ly, “ike AHICA Form 3110-1008, August 2003 , Sey . 7 @6-18-'@8 12:13 FROM-A.H.C.A 7275521448 T-584 P@18/@51 F-@56 Has the applicant been Ne permanently suspended, or excluded from the Medicare or Medicaid programs? Yes No. If yes, please provide a description and explanation eee Has any officer, partner/associate/firm member, director, of person owning at least 5% or more ob the No. If facility ever been convicted of any offense prohibited by section 435.04, F.S.? Yes yes, please provide a description and explanation: a enn Oe List two references of whom the agency may inquire as to the owner's, administrator’, and financial officer’s character, reputation, and financial responsibility. am “A ‘ City/State/Zi Telephone # ojo Wie __ Sf RPC , (Signature) : sate STATE OF FLORIDA COUNTY OF Miaan - Dacie. ia fe, BEFORE ME, the undersigned authority, fede Pretec it Ue _ personally appeared, and after first being duly swom in, did depose and say that he/she did . execute the foregoing Assisted Living Facility Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. : SWORN TO AND SUBSCRIBED before me this N aay of _ 200 i NOTARY PUBLIC My commission expires: NA e& Personally known or Produced identification _.-~ Type of identification produced Gi HZ IG GF. C4O- | FL. Drivers Lice nse. , @6-18-'@8 12:13 FROM-A.H.C.A 7275521440 7-584 P@21/051 F-@56 Attachment B ASSISTED LIVING FACILITY (ALF) BACKGROUND SCREENING : A¥FIDAVIT OF COMPLIANCE SECTION 400.4174, FLORIDA STATUTES Under penalty of perjury, [ lexi eda do hereby (Print Name) certify that I currently comply with the background screening requirements of Chapter 435, Florida Statutes, for (please check the appropriate box): - [YY Level 1 Screening [ Hon ale STATE OF FLORIDA COUNTY OF Miao: Dace ‘BEFORE ME, the undersigned authority, A Lovig 4 peedie duly sworn in, did depose ahd say that he/she did personally appeared, and after first being 0 execute the foregoing Assisted Living Facility Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. , SWORN TO AND SUBSCRIBED before me this_/¥_ day of OTARY PUBLIG; N Y ita, GONZALES My commission expires: Soe % = rs a* *, Fox AVE Personally known or Produced identification uw ,/ = Xe =. Zh, www | es Type of identification produced A 260e%-O1D-43 “AN -O % S Se ttt oe FU. Dewees LCE. May Pata aK @6-18-'@8 12:13 FROM-A.H.C.A 7275521446 T-584 P@22/051 F-@56 ; Attachment C ASSISTED LIVING FACILITY (ALF) LICENSE RENEWAL APPLICATION BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE SECTION 400.4174, FLORIDA STATUTES Under penalty of perjury, 1, C iGuide Fertricis Gralv is as owner (Owner or Administrator Name) and/or administrator of Mirnrg. Ce-ote do hereby certify Facility Name) that all persons for whom background screening is required pursuant to section 400.4174, Florida Statutes, are in compliance, and have no disqualifying offenses. . } / os (Si ) (Date) STATE OF FLORIDA COUNTY OF Miami - Dade. BEFORE ME, the undersigned authority, { Lye dua. Vetevcrn on i WG personally appeared, and after first being duly sworn in, did depose and say that he/she did execute the foregoing Assisted Living Facility Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. SWORN TO AND SUBSCRIBED before me this_/ day of 2005 My commission expires: Personally known or Produced identification 6” ‘| Mita, “a Fy yan 3 ef “agi A avee! * ET ‘Type of identification produced oon by eee 1D Neanenener DAYAM! GONZALEZ RECEIVED MY COMMISSION # DDE24292] ALL. UNIT EXPIRES December 20. 2010 JUN 9 8 2007 AHCA Recommended Form ABALEHACHATSOROMPLIANCE Page 3 of 3 @6-18-'@8 12:15 FROM-A.H.C.A 7279521446 T-584 P@37/051 F-@56 I soe eye i . 0 ef i 2 ay ad ae Pt 499 Health Care Ligensing. i Application Addendum: THIS FORM IS RECOMMENDED FOR USE TO COMPLY WITH THE REPORTING REQUIREMENTS PURSUANT TO CHAPTER 408, PART Il, FLORIDA STATUTES. PLEASE FILL OUT THE INFORMATION AS APPLICABLE TO THE ENTITY REQUESTING LICENSURE: | ProvideriFacility.Type: _. APL " * "National Provider 1D#:_ W/77 ra — (applicable) Y IE CENTEL2- a - Provider/Facility Name AUTHORITY: Pursuant to subsections 408.806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and social security number of the applicant and each controlling interest if the applicant or controlling interest is an individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling interest if the applicant or controlling interest is not an individual, Disclosure of your social security number is mandatory. The Agency for Health Care Administration shall use such information for purposes of securing the proper identification of persons listed on the application for licensure. -. - 2, Controlling Interests of Licensee A. Individual and/or Entity Ownership of Licensee Provide the following information for each person with 5% or greater ownership interest in the licensee/provider. This information must match the information contained in Section 2A of the Health Care Licensing Application. Attach additional sheets ifnecessary. - : SOCIAL SECURITY NUMBER AHICA ea Form . A.L.UNIT Page 1 of 3 JUN 2.8 2007 HEALTH FACILITY COMPLIANGS , @6-18-"68 12:15 FROM-A.H.C.A 7275521446 7-584 P@38/051 F-@56 SN A B. —_ Board Members and Officers of Management Company Provide the following information for each person that serves as an officer or is on the board of directors (excludes voluntary board members). This information must match the information contained in - Section 3B of the Health Care Licensing Application. Attach additional sheets if necessary. SOGIAL SECURITY NUMBER 4. __ Affidavit 1, _\Ysel femandez,, hereby swear or affirm that the statements in this application are true and correct. Moet Mera, Adm? Signatueé of Licensee or Authorized Representative © © °°’ Title . COUNTY OF DD &. Sworn to and subscribed before me this. day of DAG a4 sen) wy Nee VU Heaninarper This individual is personally known to me or produced the following identification: FUDAN Diweo Ucenise 20, 2010 cor ED ALL, UNIT JUN 28 2007 raireree ES tae @6-18-'@8 12:15 FROM-A.H.C.A 7275521448 T-584 P@39/@51 F-@56 aan a B Board Members and Officers of Licensee Provide the following information for each person that serves as an ‘officer or is on the board of directors (excludes voluntary board members) for the licensee/provider. This information must match the information contained in Section 2B of the Heaith Care Licensing Application. Attach additional sheets if necessary. FULLNAME SOCIAL SECURITY NUMBER -Director/CEO [President Q.Se7_] Vice-President | 4] 3. . Management Company Controlling Interests if a company other than the licensee manages the licensee/provider, complete the following information: A. Individual and/or Entity Ownership of Management Company Provide the following information for each person or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. This information must match the - information contained in Section 3A of the Health Care Licensing Application. Attach additional sheets if necessary. : FULL NAME of INDIVIDUAL - | SOCIAL SECURITY NUMBER WEALTH FACILITY CG" AHCA Recommended Form Page 2 of 3 ; @6-18-'@8 12:15 FROM-A.H.C.A 7275521448 \ mayo 7 women eel eu Find OG G8 PA AU a T-584 P@40/051 F-256 Health Care Licerisin Application Addendum,’ Ne / be ORM IS RECOMMENDED FOR USE TO COMPLY WITH THE REPORTING REQUIREMENTS . TO CHAPTER 408, PART 4, FLORIDA STATUTES. PLEASE FILL OUT THE INFORMATION AS APPLICABLE TO THE ENTITY REQUESTING LICENSURE: Provigeuraciity Typa: __ PALF Nationa Provider 18 Bye NTS4HT es mane Provi : AUTHORITY: Pure uant to subsections 408.806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and social seourlty number of the applicant and each controlling interest if the applicant or controlling interest is an individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling intereet if the applicant or cortrofing imarast is not an individual. Disclosure of your social secumty number is mandatory. The for Health Care Adminiatration shall use auch information for purposes of aeouring the proper identi ion of porgons leted on the application for licanaure. smn en nr lca AS A YS 2, _Controlling Interests of Licensee A. Individual and/or Entity Ownership of Licensee Provide the following information for aach person with 6% or greater ownership intesast in the (wer seefprovider. This information must match the information contained in Section 2A of the Health Care Licensing Application. Attach additional sheets if necessary. SOCIAL SECURITY NUMBER @6-18-'88 12:15 FROM-A.H.C.A 7275521440 T-584 P@41/@51 F-056 + 7 ___SEP-21-2007 FRI 04°09 FH UM CENTER ¥ B. _ Board Members and Officers of Licensee _ Provice the following information for each person that serves as an officer oF Is on the board of directors (excludes voluntary board mambers) for the ticensee/provider, ‘This information must match the inforrration contained in Section 28 of the Health Care Licensing Application. Aitach additional sheets If hecessary. eam er pT A TT Nn 3.__Management Company Controlling Interests Hf.a company other than the licensee manages the licenseefprovider, complete the following information: A. __ individual and/or Entity Ownership of Management Company Provide the following information for each person or entity (corporation, partnership, aasociation) . with 5% of groater cwnership interest in the management company. ‘This information must match the information contained in Section 3A of the Health Care Licensing Application. Attach additional sheets if necessary. FULL NAME of INDIVIDUAL 7279521448 T-584 P@42/051 F-056 . @6-18-'@8 12:15 FROM-A.H.C.A + SEPBT-00T FRI OAFOS PU HONS CENTER FR. 058? 25459 P05 B. _ Board Members and Officers of Management Company that serves as an officer or iss on the board of Provice the following Information for each person I eereabon must Sel ion contained in Giractors (excludes voluntary board members). This y Secticn 38 of the Health Care Licensing Application, Aftach additional sheets if necessary. \ Yi hereby awear or affirm that the stalements in this application are Gue and correct. Gaaap Fd atte, Cefttten, Bignatdére of Licensee or Authorized Representative Title STATE OF Fl Savor xe, Swom to and subscribed before me this , day of aeeasst * ri paneer j : rhe . eae of 3 fom "Rreannaactannineaencncnntenrny sree nna are * @6-18-'@8 12:15 FROM-A.H.C.a 7275521440 T-584 P@43/051 F-056 a ce ee re ee fr 2 sure / y enn . 29 Assisted Living Facitify Lg Application Ad 4 pitt SOs : | Kegs ik _ Pursuant to section 429.11(3), Florida Statutes, and §8A-5.014(1){a), Florida Administrative Co nga: plete 06. The’ FUGRIOA AGENCY FOR HEALTH CARE ADMINISTRATION OBA . Fae a this form and attach to the Azsisted Living Facility Licensure Application - AHCA Form 34140-1008, Jai information provided on this form is not part of the public record as described in section 119.0721, F.S. Uunné Cemee zoe e[e [o> Facility Name The Agency for Health Care Administration is required to obtain your social security number pursuant to section 429.11(3), Florida Statutes. Disclosure of your social security number is mandatory, Your social security number will be used to secure the proper identification of persons listed on this application for licensure. : If the applicant is a corporation, please enter the name and social security number (SSN) for each officer, director, and person having at least a 5 percent or greater ownership interest; enter the nama and SSN for each member of a firm, partnership, or association; enter the name and SSN for each individual owner, administrator, and person having responsibility for the facility's financial operation. . Full Name - Social Security Number \sel Hernandee . a a a RECEIVE, ALL, UNIE JUN 28 2007 MALTY FACHITY COMPLiANCS AHCA Form 3110-1016, Jan. 06 AHCA ALU, 2727 Mahan Drive, MS 30, Tallahassee, FL 32308 (850) 487-2515 Fax: (850) 410-1476 Form available: hitp:/ahca.myflorida.convMCHO/Long_Term_Care/Assisted_living/alf.shtml a6-18-'@8 12 :16 FROM-A.H LCA 72755214408 7-5 -584 P@44/@51 F ~056 i, eee yi ne ee es) . a ~ Pa) ~ 1 = ~ ~~ ~ = RECEIVED AL. UNIT JUN 28 2007 ~ ypanty FAGIITY COMPLIANCE @6-18-'@8 12:16 FROM-A.H.C.A 7275521440 wan SEP 2127 FRI 05:53. PY HONNE CEI 7-584 P@45/051 F-056 , = = } awe ee ‘ - : ' ty aL ory fy ase fp th 7 7a 2 7h a REMENTS } THE REPORTING REQUI TION AS THIG FORM 1S RECOMMENDED FOR USE 7 COM TEE. PLEASE FILL OUT THE INFORMA’ PURSUANT TO CHAPTER 408, PARTE Tac LOR SURE: Zip Gily State 3. Co Interests of Licensee AUTHORITY: . on for Reanaure must inciude: the ‘ (P), ah applic Pursuant to eubseotions 408.806(1Xa) and a) or athe eppheant and wach coving Mires Tt Terapar (IN) of te rare, eres and social eee Tr the nerne, address, and federal a controling intereat Is 3 ps eh 7 esi Heath Care Adminisreion shall use eu er en cpcial security number ie mandatory. The er perecne fated cn this application for leans An gocial security purposes of securing the open een identifica not iychide social sacurity Mumbare effort fo pect a pam ye Ackendum tothe Appicato: , September 26, 2006 AZICA Rocommanded Form 86-18-'@8 12:16 FROM-A.H.C.A 7275521440 T-584 PQ46/051 F-@56 SEP-21-2007 FRI 06:53 PH AUNNE CENTER PAX NO. “O58235459 Poe - we ee 2 Controfing interests, 1 orllcensee;2 subsection 40B.803(7}, Florida Statutes, are the applicant ore . person ; ania set ad fe oa SAH Lar acer level ot art sa an fer oy tat eave oman fica oh. on Mee | basal - . rege tne provide’ Te tar does nok include a voluntary board w ‘ ntracts to . with which the applicant or licanaee co member. ber of a Jorda Statutes, means a board mer otuntary Board Member, as defned in subsection 408.805) F ee es not wy a gerves solely voluntary receve capa ow ne D Jal interest in the n fenuneration SOTVICES board tore, and has no finaricia! im corporation em zatth fl of et eran One of board member mut be uta 1 We SUSY provided by the agency. A. individual andior Entity Ownership of Licensee provide te oknwing norman foreach parson of ently (COFPESEC fh association) with 9% oF parters ip, } greater he one i orent inthe Hoensee/provider. , Attach additional sheets if necesuary. B Board Members end Officers of Licensee Provide the fol a tion f } fi . the | tof dl f board 1) the licensee/provider. Attach additional st ects F necacsary. (excludes vetuntary members: tor x @6-18-'@8 12:16 FROM-A,H.C.A SEP-21-200" FR 7275521446 7-584 P@47/051 F-@56 1 05:63 PH MINKE CENTER FRR 80, 58236869- #8 c. Voluntary Board Members and Officers of Licensee rman her for the person that serves as 6 voluntary poate Mere tor rota en aaah Ven Bs: A = TS ven vounisry board member. P Howing information. ~ recoapacy eer than te cence manages tre sangaarnet, ape 2 2 ng A. individual and/or Entity Ownership of Management Company Provide the following information hip, association) with 5% oF partnership, ) v for each person of entity (corporation, ' greater ownership interest in the management company. Attach additional sheets it necessaly @6-18-'@8 12:16 FROM-A.H.C.A 7279521446 T-584 P@48/@51 F-@56 Bb. Bosnt Members and Officers of Management Company Provide we follwing information for each person that serves as an officer oF won the board of director Ss exclucies voluntary board members) for the management company. Attach additional sheets if necessary. ( nt Provide jawing infortmati person board membar for the manageme fing i that serves asa voluntary ne rast Prove och ng infra ccnesat. A Voluntary Board Member Affidavit must attached voluntary board member. , Septeenberr 26, 2006 AHCA Recommended Form Page 4 of 5 @6-18-'@3 12:16 FROM-A.H.C.A Pa ee T-584 P@49/051 F-@56 ¢ a SEP-RI-2O0T FAT 05°51 PHPORNE CENTER ———FRH0--0 ee one em tn ae ea ews 058235489 8.1 7275521446 4. Provider Fines and Financial information - Pursuant to subsection 408,831(1)(4), Florida Statutes, the Agency may take action againet the applicant, foencsee, purr to utmacon 8 88 ars cmon canny eres ah e Pr Ye ete pay al outstanding fines, is at which ear goaaoeased by fal order othe agency o¢ al nee es Centers for Medicare and Medicaid Servioes, not subject to further appeal, unless & repayment plan Is approved by the agency. . aia Ave thers atty incidences of —/ liens or overpayments #5 described above? yes) NO B, if yes, pease complete the fooymg for each incidence (attach additional eneets if necessary): Amount. $ / / Assesaed by: A Agency for Health Care Administration Canters for Medicare and Medicaid Services Date of related Inspection, application, or overpayment period itapplicable: Due date of payment: Is there an appeal pending from a Final Order? ves (1 no O Please attach a copy ofthe approved repayment plan if applicable. i 5. _ Affidavit - TT " . yser Lhenandee-_ hereby swear ra that he ststeme in tis application are tse ane Qaeeat : Signature or ti epresentnive: Title STATE OF F SA oF Dade. Swom to and subscribed betore me this day of 2 foam Yael 0 slea seeds This Individual is personally known to me or produced the following i .¢ 3 ARICA Reocmended Form FL ROAR Batt, Septanes 26, 2006 Page $ of $ i aks fj + ae ? B fat Pea eace | Fs reese we i ie | . Ey amen Hanes he, GMA AMP

Docket for Case No: 08-003695

Issue Date	Proceedings
Aug. 08, 2008	Order Closing File. CASE CLOSED.
Aug. 06, 2008	Motion to Relinquish Jurisdiction filed.
Jul. 29, 2008	Initial Order.
Jul. 28, 2008	Administrative Complaint filed.
Jul. 28, 2008	Petition for Formal Administrative Hearing filed.
Jul. 28, 2008	Amended Petition for Formal Administrative Hearing filed.
Jul. 28, 2008	Notice (of Agency referral) filed.