STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2009005330 Return Receipt Requested: v. 7009 0080 0000 0586 6898 7009 0080 0000 0586 6904 MED-CARE MEDICAL CENTER, INC. d/b/a MED-CARE MEDICAL CENTER, 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 Med-Care Medical Center, Inc. d/b/a Med-Care Medical Center, Inc. (hereinafter “Med-Care Medical Center, Inc.”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2008), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the health care clinic license [License No.: 5018] and to impose an administrative fine of $5,000.00 pursuant to Sections 400.995, Florida Statutes (2008) and Rule 59A-33.008, Florida Administrative Code, for the protection of public healtg EXHIBIT ——__| Filed October 27, 2009 4:07 PM Divi: arings. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2008), and Chapter 28-106, Florida Admin . “od 2008) 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2008). PARTIES 4. AHCA is the regulatory authority responsible for. licensure and enforcement of all applicable statutes and rules governing health care clinics pursuant to Chapter 400, Part X, Florida Statutes (2008), and Chapter 59A-33 , Florida Administrative Code (2008). 5. Med-Care Medical Center operates a health care clinic located at 9766 S. W. 24° Street, Miami, Florida 33165. Med-Care Medical Center is licensed as a health care clinic under license number 5018. Med-Care Medical Center 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 TI MED-CARE MEDICAL CENTER OPERATED A HEALTH CARE CLINIC WITHOUT A MEDICAL OR CLINIC DIRECTOR. SECTION 400.9935(1), FLORIDA STATUTES SECTION 400.995({(1), FLORIDA STATUTES SECTION 400.9912(1), FLORIDA STATUTES SECTION 400.9935(1) (a)-(h), FLORIDA STATUTES SECTION 408.831, FLORIDA STATUTES RULE 59A-33.008, FLORIDA ADMINISTRATIVE CODE RULE 59A~-33.012, FLORIDA ADMINISTRATIVE CODE (MEDICAL DIRECTOR STANDARDS) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Med-Care Medical Center was cited with one (1) deficiency as a result of a complaint investigation survey conducted on April 14, 2009. 8. On March 26, 2009, the Agency was notified by Dr. Armando Segui that he had resigned from the medical director position at Med-Care Medical Center Inc on February 15, 2008. 9. On March 27, 2008, The Agency ordered a complaint investigation survey be conducted to determine if the clinic had been operating without a medical director since February 15, 2008. 10. On April 14, 2009, a survey was conducted which supported Dr. Armando Segui’s statement that he resigned as medical direct on February 15, 208 and that Med-Care Medical Center had operated since that date without a medical director. 11. On April 23, 2009, Med-Care Medical Center appointed a new medical director. 12. Based on the foregoing facts, Med-Care Medical Center ———-vLekated—Seetton—406,9935(h,\_+#tiortda—Statutes; Section 400.995 (1), Florida Statutes, Section 400.9912(1), Florida Statutes, Section 400.9935(1) (a)-(h), Florida Statutes, Section 408.831, Florida Statutes, Rule 59A-33.008, Florida Administrative Code, Rule 59A-33.012, Florida Administrative Code, which warrants a revocation of the health care clinic license, and warrants a $5,000.00 administrative fine. 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 Med-Care Medical Center on Count I. 2. Revoke the health care clinic license [License No.: 5018] of Med-Care Medical Center for the violation cited above. 3. Assess an administrative fine of $5,000.00 against Med-Care Medical Center on Count I for the violation cited above. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent —_is_nrottfted _that—_it has —_a_right _to request air administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2008). 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 Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 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) Health Care Clinic Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Juan Camayo, Administrator, Med-Care Medical Center, 9766 S. W. 24% Street, Miami, Florida 33165; Carlos Navarro, Registered Agent, 11417 8S. W. 245 Street, BR Gestead, Florida 33032. on this VS day of , 2009. Ay tl2, aro ourdes A. Naranjo, Esq. i t SENDER: COMPLETE THIS SECTION ® Complete Items 1;°2, and 3. Also complete item 4 if Restricted Delivery Is desired. COMPLETE THIS SECTION ON DELIVERY D Agent a Print your name-and-address-on the reverse ; _ so that we can return the card to you, ; ™@ Attach this card to the back of the mallpiece, or on the front if space permits. Cantified Fee 7 1 Article Addressed to: Return Recat (Endorsement Require Rostiicted Deliver (Endorsement Roane ho Sw 24 Ato Wea. Fdoider 23kS 3. O09 0040 oo00 os, ends gaad oo00 0586 ba Service Type [1 Certifled Mall OC Registered 1 Insured Mail A Onsttntad Delivery? (Extra Fee) (iransfer from service label) PS Form 3811, February 2004 EXHIBIT a tabbies Domestic Return Receipt (id Min D. Is delivery address different from item 17) C1 Yes If YES, enter delivery address below: (Express Mal No C Return Recelpt for Merchandise 11 c.0.D. Com 102595-02-M-1540 H STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Med-Care Medical Center, Inc. d/b/a AHCA No.: 2009005330 Med-Care Medical Center, Inc. ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY | OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that.by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___—Ss dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointe EXHIBIT ninistrative Hearings. PLEASE NOTE: Choosing OPTION THI INOT sufficient to obtain a formal hearing. You also must file a writt btain a formal hearing before tabbies” 2d ‘the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none, Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC

Docket for Case No: 09-005962