STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 20120001 85 RACHEL HILL d/b/a PEACOCK HILL,! Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Rachel Peacock d/b/a Peacock Hill (“the Respondent”) and alleges as follows: NATURE OF THE ACTION This is an action seeking to impose an administrative fine of $32,000.00 based upon the Respondent’s unlicensed activity from December 5, 2011, to J anuary 5, 2012, plus $1,000.00 per day for any continued unlicensed activity that may be established at hearing. . PARTIES 1, The Agency is the licensing and regulatory authority that ovérsees assisted living facilities in Florida and enforces the applicable state statutes and rules that govern such facilities, Chs. 429, Part I, and 408, Part II, Fla. Stat. 2. The Respondent, Rachel Peacock d/b/a Peacock Hill, was previously issued a ' This fictitious name is not registered to the Respondent, Rachel Peacock. Nevertheless, the Respondent has used this fictitious name and has listed it in her license application. Filed January 31, 2012 10:16 AM Division of Administrative Hearings renewal license to.operate a 13-bed assisted living facility located at 458 NW Marion Street, Madison, Florida 32340. The Respondent was licensed to operate this assisted living ‘facility (License Number 10759) from December 5, 2009, to December 4, 2011, and was at all times required to comply with applicable statutes and rules. Ex. A. On the face of the license, it is stated that the the license is being issued “to permit the continued operation of your facility for the period specified.” Assisted Living Facilities 3. Under Florida law, “assisted living facility” means “any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or mote adults who are not relatives of the owner or administrator,” § 429,02(5), Fla. Stat. (2011). 4. Under Florida law, “personal service” means “direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services which the department may define by rule. ‘Personal services’ shall not be construed to mean the provision of medical, nursing, dental, or mental health services,” § 429,02(16), Fla. Stat. (2011). 5. Under Florida law, “activities of daily living” means “functions and tasks for self- care, including ambulation, bathing, dressing, eating, grooming, and toileting, and other similar tasks.” § 429,02(1), Fla. Stat. (2011). COUNT I Unlicensed Assisted Living Facility 6. Under Florida law, it is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the operation or maintenance of such provider. § 408.804(1), Fla. Stat. (2011). A license must be displayed in a’ conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. § 408.804(2), Fla. Stat. (2011). 7. Under Florida law, a person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license, § 408.812(1), Fla. Stat. (2011). 8. Under Florida law, “services that require licensure” means “those services, including residential services that require a valid license before those services may be provided in accordance with authorizing statutes and agency rules.” § 408.803(12), Fla. Stat. (2011). 9. Under Florida law, the operation or maintenance of an unlicensed provider or the performance of ‘any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The Agency or any state attorney may, in addition to other remedies provided in this part, bring an action fot an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. § 408.812(2), Fla. Stat. (2011), 10. Under Florida law, it is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the Agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable tules, Each day of continued operation is a separate offense. § 408.812(3), Fla. Stat. (201 1). " 11. Under Florida law, facilities to be licensed ‘by the Agency shall include’ alt assisted living facilities as defined in this part. § 429.04(1), Fla. Stat. (2011). 12: Under Florida law, it is unlawful for any person or entity to own, operate, or maintain an assisted living facility without obtaining a license, the violation of which is a, felony of the third degree. § 429.08(1)(b), Fla. Stat. (2011). ) 13. Any person or entity that fails to cease operation after Agency notification may be fined $1,000 for each day of noncompliance. § 408.812(4), Fla. Stat. (2011). 14, On August 22, 2011, the Agency issued a renewal notification to the Respondent by United States Certified Mail, which was delivered on September 1, 2011. Ex B. As set forth in the beginning of the notice: “The license to operate the above-named provider/tacility expires 12/04/2011. Itis a violation of Florida Statutes to operate without a valid license.” Ex. B. 15. The Respondent failed to submit a license renewal application to the Agency and thus failed to renew this assisted living facility license. 16. On December 6, 2011, the Agency issued a failure to renew letter to the Respondent by United States Certified Mail, which was delivered on December 15,2011, Ex. C The failure to renew letter notified the Respondent that this assisted living facility license had expired and that any continued operation of the assisted living facility constituted unlicensed activity, Ex. C 17. On December. 22, 2011, the Agency conducted a visit of the Respondent. 18. Based upon observation, record review, and interviews of the residents and staff, the Respondent continued to provide services to its 13 assisted living residents and continued to operate an assisted living facility, even after being notified by the Agency that she had failed to renew this license to operate as an assisted living facility. 19. On December 22, 2011, the Agency conducted a monitoring visit of the facility and observed the Respondent’s continued operation of the’ assisted living facility with the Respondent providing services for the 13 residents. 20. At approximately 9:50 am, an interview was conducted with Resident #1, who reported that the Respondent's staff gives him his medication. 21. At at approximately 9:55 am, an interview was conducted with Resident #2, who reported that the Respondent’s staff gives him medication morning and night. 22. A review of the residents’ health assessments and medication observation records revealed the following for each resident: a. Resident #1 receives medication management. b. Resident #2 receives medication management. c. Resident #3 receives diabetic and hypertension (HTN) management and also self administers his or her medication. d. Resident #4 receives medication management. e, Resident #5 receives blood pressure monitoring weekly and as needed (PRN) and staff assist with the self-administration of medication. f. Resident #6 receives help in obtaining medication. g. Resident #7 receives monitoring with blood pressure and blood sugar. h. ~ Resident #8 requires monitoring with self-administration of medications. i. Resident #9 receives medication management. j. Resident #10 receives assistant with self-administration of medications. k. Resident #11 receives medication management. lL. Resident #12 receives limited nursing services, assistance with medication management and blood pressure monitoring. m, Resident #13 receives limited mental health, limited nursing services, assistance with self-administration of medication and blood pressure monitoring. 23, On December 22, 2011, at approximately 11:00 am, an interview was conducted with Rachel Peacock, the Owner and Administrator of the facility, who claimed that she had submitted the documentation to renew the facility's assisted living license and the Agency has lost all documentation. 24, The Respondent confirmed that the facility was still operating with a census of 13 residents, 25, The Respondent was given a copy of the Notice of Unlicensed Activity letter and a copy of the letter was kept with the Respondent’s signature and date. 26. Based on observation and interview, the Respondent failed to cease operation and transfer the residents after being notified of the failure to renew her license by the Agency, 27, On January 4, 2010, the Respondent hand-delivered an initial application to the Agency and represented to the Unit Manager that all of the residents had been discharged from the facility. Ex. D. 28. On January 5, 2012, the Agency conducted a follow-up monitoring visit to verify the Respondent’s representations. 29. On that day at approximately 11:00 am, assisted living residents were observed to be residing at the facility. 30. A facility employee provided the Agency surveyor a list of names of residents, which included 13 names. 31. The facility employee confirmed that the 13 resident names were the same residents who had been residing in the facility during the December 22, 2011, visit by the Agency surveyors. ) 32. The facility employee stated that copies of the 13 resident's face sheets had been previously obtained by Agency surveyors during the December 22, 2011, visit. 33. An interview was conducted with the Respondent at approximately 1 1:30 am. 34, She confirmed there are currently 13 residents at the facility and that there ‘were 0 plans to transfer the residents to other facilities. 35. She stated that she had submitted a license renewal application and a check for $851.00 to the Agency on November 15, 2011, by regular mail, that the application was apparently lost, and that she has resubmitted an application and has retained an attomey to assist her in this matter. 36. After receiving multiples notices from the Agency, the Respondent continued to violate the requirements of the law by operating an unlicensed assisted living facility. 37. The $32,000.00 fine is calculated from the date of license expiration (12/04/2011) through the date of the monitoring visit (01/05/2012), plus $1,000.00 per day of any additional unlicensed activity that may be established at hearing. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine of $32,000.00 plus $1,000.00 per day of any additional unlicensed activity that may be established at hearing. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1. . Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. “Respectfully submitted on this_/22- day of J anuary, 2012. hoe Enfinger Florida Bar No. 793450 Office of the General Agency for Health Care 2727 Mahan Drive, Ma d Tallahassee, Florida 32308 Telephone: (850) 412-3630 Facsimile: (850) 921-0158 NOTICE The Respondents is notified that it has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. The Respondents has the right to be represented by an attorney in this matter at the Respondents’ expense. Specific options for administrative action are set out in the attached Election of Rights form. The Respondents is further notified if the Election of Rights form is. not received by the Agency Clerk for Agency for Health Care Administration within twenty-one (21) days by 5:00 p.m., Eastern Time, of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care- Administration and deliyered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE T HEREBY CERTIFY that a true and correct copy of the foregoing has been served to: Rachel Peacock, 458 NW Marion Street, Madison, Florida 32340, by U.S. Certified Mail, Return Receipt No. 7011-1570 0000 3003 0400, and Theodore E. Mack, Esquire, Mack and Powell, 803 North Calhoun Street, Tallahassee, Florida 32303, by facsimile transmission on this 7&2 day of January, 2012. D. Carlton Enfinger II, Assystant General Counsel Florida Bar No. 793450 Agency for Health Care 2727 Mahan Drive, Mail Tallahassee, Florida 32308 Telephone: (850) 412-3690 Facsimile: (850) 921-0158 CHARLIE CRIST FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION. THOMAS W. ARNO Is ope : LD GOVERNOR Better Health Care for all Floridians SECRETARY December 4, 2009 PEACOCK HILL (LIC#: 10759) 458 NW MARION STREET MADISON, FL 32340 Dear Administrator: The enclosed STANDARD License (with LIMITED MENTAL HEALTH, LIMITED NURSING SERVICES )is issued for the period December 05, 2009 to December 04, 2011 for a total capacity of 13, 13 OSS and 0 Private Pay Residents. This Standard License is being issued as a renewal license to permit the continued operation of your facility for the period specified. Maintaining high standards of resident care are essential to retaining a Standard License. ; If you have any questions or need assistance, please contact the Assisted Living Facility Unit at (850) 487-2515. ; Sincerely, Patrice Spicer Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce; LTCOC, District 2 EXHIBIT 2727 Mahan Drive, MS#30 Visit Tallahassee, Florida 32308 http://ahcas 1 CERTIFICATE #: 29287 ——— TICENSE Ar 10760 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH, LIMITED NURSING SERVICES) STANDARD This is to confirm that RACHEL PEACOCK has complied with Chapter 429, Part I, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: PEACOCK HILL 458 NW MARION STREET MADISON, FL 32340 MADISON COUNTY TOTAL CAPACITY: 13 Optional State Supplementation Residents: 13. Private Pay Residents: 0 EFFECTIVE DATE: December 05, 2009 | EXPIRATION DATE: December 04,2011 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: RICK SCOTT ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians SECRETARY (Orermalite clo fy 5 August 22, 2011 rtified Article Numbers PEACOCK HILL 2L56 F004 9132 1946 OOND IL : . 458 NW MARION STREET : SENDERS RECORD MADISON, FL 32340 Re; Renewal notification for assisted living facility license number 10759 Dear Administrator: The license to operate the above named provider/facility expires 12/04/2011. It is a violation of Florida Statutes to operate without a valid license. In order to continue to operate, complete the licensure application and AHCA forms available from the AHCA website at http://ahca.myflorida.com/assistedliving and return with the appropriate license fee, Payment must be in the form of a check or money order made payable to the Agency for Health Care Administration. Retum the completed application and fee to: The Agency for Health Care Administration 2727 Mahan Drive, Mail Stop # 30 Tallahassee, Florida 32308-5407 Attention: Assisted Living Unit Application Fees: Standard $37! plus $62 per private bed; $0 for OSS bed; Maximum standard license fee shall not exceed $13,644, ECC $523 plus $10 per resident based on total licensed resident capacity. LNS $309 plus $10 per resident based on total licensed resident capacity. ECC and LNS license fees are in addition to the fee for the standard license, The application and fee are due sixty (60) days before the expiration date noted above. Failure to file a renewal application within this time frame will result in a late fee as allowed by Florida Statutes. Applications without licensure fees will not be accepted and the application will be retumed without processing. Applicants must comply with the requirements of Chapter 408, Part II, Florida Statutes in addition to the requirements of home health agency licensure in Chapter 400, Part IH, Florida Statutes and Chapter 59A-8, Florida Administrative Cade. Additional information may be obtained at the web site address above or by calling (850) 412-4304. This notice, sent pursuant to section 408.806(2)(d), Florida Statutes, does not affect any regulatory actions, sanctions, or orders that are already final or pending. The issuance of this notice in no way implies or ensures that the Agency intends to renew or otherwise approve any license renewal application submitted to the Agency. Sincerely, Assisted Living Unit Bureau of Health Facility Regulation EXHIBIT Poa 2727 Mahan Drive, MS#30 Tallahassee, Florida 32308 ten rer te USPS.com® - Track & Confirn. English Customer Seivice USPS Mobite #AUSPS.COM' Quick Toots. Ship a Package Send Mail Track & Confirm You entered: 7196900891 1119660040 Status: Delivered Your Item was delivered at 16:07 am on September 04, 2011 in MADISON, FL 32340, Additionat information for this item ts stored in files offline, Additional Informatlon for this item is stored in files offilno, You may request that the additional information be retrieved from the archives, and that we send you an e-mail when this retrieval is complete. Requests to retrieve additional information are t would like lo receive notification on this request Restore Find Another item What's your label (or receipt) number? Find LEGAL ON USPS,COM Privacy Policy» Government Services > Terms of Use > Buy Stamps & Shop» FOIA» Print a Label with Postage » No FEAR Act EEO Data? Customer Service » Site Index > Copyright® 2012 USPS. All Rights Reserved, generally processed within four hours, This information will remaln online for 30 days. Manage Your Mail ON ABOUT,USPS.COM Aboul USPS Home » Newsroom Mail Service Updates » Forms & Publications » Careers > Page 1 of | Register / Signin Search USPS .com or Track Packages Shop Business’ Solutions OTHER USPS SITES. Business Customer Galeway > Postal Inspectors » lospactor General > Postal Explorer) Certified Article Number 719_ 9008 F442 3708 Bu75 ISENDERS RECORD FLORIDA AGENCY FOR HEALTH CARL ADMINISTRATION EUCADEIM aauy fmt aN GOVERNOR better Health Care forall Floridians SECRETARY December 6, 2011 SEpntrirign RACHEL PRACOCK LICENSE NUMBER: 10759 PEACOCK. HILL 312 SE ASKEW AVENUE MADISON, FL 32340 Re: Failure to Renew License for Peacock Hill Dear Ms, Peacock: The linense to operate as Peacock Hill expired on Decumber 4,201, No renewal application Liny been filed, Pursuant to 408.806(2), F.S., notification was provided indicating that a renewal application is necessary for continued operation as an assisted living facility. Peacock Till no longer holds a license to Operate as an assisted living facility and if currently Operating must immediately cease operation and transfer all residents, Failure to immediately cease operations and transfer alt residents is unlicensed activity and may result in a referral to law enforcement and Other regulatory sanctions, Pursuant to 408,812, F.S., any health care licensee related to this provider may also bo subject to fines for unlicensed activity, To apply for @ new license for an assisted living facility pleaso visit the Agency website and download the initial license. application forms, The web address is hitp://ahca. myflorida.com/MCHO/Lone, Term Care/Assisted_living/alf.shtm. Complete the application forms and other documentation and send with the appropriate fees to the Long ‘erm Care Unit, Tf you have additional questions or concerns regarding this letter, please contact the Assisted Living Unit at (850) 412-4314, Sincerely, Shaddrick Flaston, Manager Assisted Living Unit Division of Health Quality Assurance Agency for Health Care Administration ce; ‘Tallahassee Field Office 2727 Mahan Drive, MS#30 Tallahagsoo, Florida 32506 a \ Le USPS.com® - Track & Confirm. English Customer Service HIUSPSCOM Quick Tools Track & Confirm GET EMAIL UPDATES PRINT DETAILS YOUR LABEL NUMBER 71969008911137088475 ; ! | Check on Another item What's your label (or receipt) number? LEGAL Privacy Policy » Terms of Use FOIA No FEAR Act EEO Data > Copyright® 2012 USPS, All Rights Reserved. USPS Mobite Ship a Package Send Mail SERVICE STATUS OF YOUR ITEM | Delivered | Nolice Left Depart USPS Sort Facility | Processed through USPS Sort Facility Find ON USPS.COM Governmant Services > Buy Stamps & Shop + Print a Label with Postage » Customer Service > Site Index > Page 1 of i Register / Sign in Search USPS.com or Track Packages Manage Your Mail Shop Business Solutions OATE & TINE LOCATION FEATURES, { { December 15, 2014, 12:28 pm | MADISON, FL 32340 | . i | t December 14,2011 TALLAHASSEE, FL 32301 1 1 December 16, 2011, 12:31 pm | MADISON, FL 32340 Cerlifed Mail i { i December 14, 2011, 12:08 am | TALLAHASSEE, FL $2304 { | { 1 I | ON ABOUT.USPS.COM OTHER USPS SITES About USPS Home > Business Customer Gateway » Newsroom > Postal Inspectors » Mail Service Updates » inspector General + Forms & Publications > Postal Explorer > Careers » , AHCA USE ONLY: - Fite #. Application #: Check #: . Check Amt: Batch #: FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Health Care Licensing Application ASSISTED LIVING FACILITIES Walk In _ k a7, Under the authority of Chapters 408 Part Il and 429 Florida Statutes (F.S.), and Cha pters 594-35 and 1d 58A-5, Florida Administratiy 5, Florida Administrative Code €. A, C.), an application is hereby made to operate an assisted living facility as indicated below. 1. Provider / Licensee Information complete, the following for the assisted living faclity name anc! focation. OP110 @ number wil be lsted.on http Aww One eat finder chy; License # (fot renewal & change of ownership | National Provider identifier (NPI) Medicare # (CMS CCN) Medicaid # applications) (i appticabte) C) 10154 FI 5280! ime of Assisted Bim" (# operated under a fictitious name, list that hore) 7 id eR Marion Ae Aw Marion tne - County | - se te Zip Lv) CAC] Bla ace IRAO) Telephone Number : Fax Number E-mail Address ~~ Provider Website ~ Q (VAD AI\ D333 -2lGor OC) AOI aw) ananing Address or kf” Same as above (AN mail will be sent to this awk State ontact Person for this application : ontact Tele phone Num IPvache CACEA 650) Stal &Lo Contact e-mail raddress or L.} Do not have e-mail NOTE: By providing your ‘i ; you agree to e-mail Pohl ecocdgvao Correspondence from the Agency 4 p hm Mailing Ad ress OF [Jame as ‘above City Siste Zip : : Telephone Number Fax Number E-mail Address JAN 04 2012 peso of Licensee (check one): Central Syst " For Profit Not for Prof . Publi "Management Unit j Corporation { Corporation State (] Limited Liability Company [2] Religious Affiliation (2) City/County ; . Brrenership [J Limited Liability Company () Hospital District Individual (] other C] Other AHCA Form 3110-1008, Revised August 2011 Page 1 of 8 Form available at: hito://a 2. Application Type, Number of Beds and Fees - te, Indicate the type of application with an °X,” Applications will not be processed if all applicable fees are not inchucieg, All fees are nonrefundable. Renewal and Change of Ownership applications must be received 60 days prior to the expiration of the license or the proposed effective date of the change to avoid alate fine. {fihe renewal application is received by the Agency less than 60 days prior to the expiration date, itis subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee ag pant of the application process or by separate notice. . A, TYPE OF APPLICATION [7 initia Licensure Was this entity previously licensed as an Assisted Living Facility in Florida? YES [~~ NO \F yes, please provide the name of the agency (if different), the EIN # and the year the prior licanse expired or closed: N AME . “ Hil | RIN ba 22 SY Year PyPrecl/Closed: CJ Renewal Licensure (7) Change of Ownership C1 Change during licensure period (C) Add Specialty License (1 Increase/Decrease in number of licensed beds (see Section 2B) (CC) Facility Name Change Proposed Effective Date: C] Other: (please specify) B. TYPE OF LICENSE Proposed Effective Date: Proposed Effective Date: ets tandard (A Timited Nursing Services (LNS) Limited Mental Health (LMH) ( Extended Congregate Care (ECC) If applying for an LNS or ECC license, has the facitty mainjained a standard license for the past two calendar years, or since initially licensed if licensed less than two years? ives (1 NO (STOP ~ You are not eligible; please skip to Section Cc) If applying for an LNS or ECC license, has the facility been sanctioned during the past two calendar years? [J YES ENO If applying for an ECC license, list the total number of ECC beds requested: !dentify the building, wing, floor, and rooms designated for ECC services: If applying for a LMH license, does the facility currently ho a Standard license and have no uncorrected deficiencies? | yes [] NO ee C. NUMBER OF BEDS Please enter the Number of Beds (currently licensed or proposed for initial applicants). NOTE: To request an increase/decrease in the number of beds Please see Section 2E. Do not include the increase/decraase number of beds in this OSS Beds; 3 + Private Pay Beds: Q = Total Beds (OSS and Private Pay Beds): kom Number of LNS Beds (ir applicable): A RECEIVED Number of ECC Beds (itappiicabley: JAN 04 2012 D. LICENSU ~ If this application is onty to request an increase or decrease in the number of licensed beds (mot for an initial renewal or change of ownership) please skip fo section 2D, ’ Action $62.00 per private pay bed x___s number of LICENSE FEE Standard ALF (Initiel, Renewal and Change of Ownership): beds + $374.00 (not to exceed $13,6-44,00) License Fee Exemption (County or Municipal Government pursuant to 428.07(5), F.S.)= $ 0,00 Specialty License - Extended Congregate Care (ECC) ls Specialty License - Limited Mental Health (LMH) $523,00 + $10.00 per bed x # of beds .| $309.00 + $10.00 per bed x 1} # of beds NO EXTRA FEE pecialty License - Limited Nursing Service (LNS) Change During Licensure Period/Replacement License $ 25.00 r : TOTAL FEES INCLUDED WITH APPLICATION: Please make check or money order payable to the Agency for Health Care Administration (AHGA) L NOTE: Starter checks and temporary checks are not accepted, E. CREA’ ‘ i TY ~ If requesting an increase or decrease in the current number Of licensed beds (not for an initial, renewal or change of ownership) please complete this section. Totat number of currently licensed beds: Total number of beds tobe ["] Increased or ["] Decreased: License Fee OSS Beds LNS Beds _| $10.00 perbed x #ofbads Mana! stem, LMH Beds | No fee required for Increase of beds. $25.00 fee to change license ECC Beds $10.00 par bed x __... # of beds : . TOTAL for SECTION D Please make check or money order payable to the Agency for Health Care Administration (ANCA) [ NOTE: Starter checks and temporary cheoke are not accepted. F. SPECIAI : /REN ~ If the facility currently holds a Standard license, and this application is to add an LNS or ECC specialty llceense between biennial license renewal periods: Action $523.00 + $10.00 per bed x # of beds (tee is prorated at $21.48 per month x the # of months until the license expires + $10.00 per bed $309.00 + $10.00 per bed x # ofbeds (fae is prorated at 12.66 per month x the # of Months until the license expires + $70.00 per bed’ No fee required for increase of beds. $25.00 fee to change license Specialty License - Extended Congragate Care (ECC) Specialty License - Limited Nursing Service (LINS) Specialty License — Limited Mental Health (LMH) L. TOTAL for SECTION E | § Please make check or money order payable to the Agency tor Health Care Administration (AKCA) : NOTE: Starter checks and terhporary checks ate not accepted. AHCA Form 31 10-1008, Revised August 2011 Section 59A-35.060(1), Florida Administrative Code ida.c 4 Page 3 of 8 Form available at: httpy/ WHOA, | 3. ~ Controlling interests of Licensee _ __. oO AUTHORITY: Pursuant to section 408.806(1)(a) and (b), Florida Statutes, an a Security number of the applicant and each controlli address, and federal employer identification number (EIN) of the applicant and each Controlling interest, # the applicant or controlling interest is not an individual, Disclosure of Social Security number(s) is mandatory, The Agency for Health Care Administration shal] use Such information for purposes of securing the pro; ’ n per identification of persons listed on this application for licensure. However, in an effort to protect all personal information, do not include Social Security numbers on this form. All Social Security numbers must be entered on the Health Care Licensing Application Addendum, AHCA Form 3110-1024. DEFINITIONS: pplication for licensure must include: the name. ing interest, if the applicant or controlling interest is an individual; and the name, ) 8ddiress and Social Voluntary Board. Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or Officer of a not-for- corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services o profit board of directors, and has no financial interest in the corporation or organization. In the in Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the licensee. Attach additional sheets if n ecessary. A. _ Individual and/or Entity Ownership of Licensee FULL NAME of INDIVIDUAL or PERSONAL OR BUSINESS ADDRESS ENTITY. B,. Board Members and Officers of Licensee - TME FULL NAME PERSONAL OR BUSINESS ADDRESS Direstoczo | Ky President | Vice President Secretary Treasurer Other: iZ AHCA Form 3110-1008, Revised Auguet 2014 Section 59A-35.060(1), Florida Administrative Code Page 4 of 8 Form available at: lahea orids com/Publications, sHO n C.. Voluntary Board Membe:_ and Officers. of Licensee {f the licensee is a not-for-profit corporation/organization, provide the requested information for each individual thet serves asa voluntary board member. Attach additional sheets if necessary. . FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER D. Administration TITLE NAME Administrator/Managing . Employee a Leacock, Chief Financial Officer . 4. Management Company Controlling interests Does a company other than the licensee manage the licensed provider? If 0, skip to section 5 - Required Disclosure, tf C1) YEs, provide the following information: Name of Management Company EIN (No SSNs) Telephone Number / Fax Street Address &-mail Address City , County State | Zip Mailing Address or []Same as above City State Contact Person Contact E-mail | Contact Telephone Number In Sections A and B below, provide the information for each individual or entity (corporation, partnersh| E : ip, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary. . A. Individual and/or Entity Ownership of Management Company FULL NAME of - INDIVIDUAL of ENTITY PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER AHCA Form 3110-1008, Revised August 2011 Section 5! Page 5 of 8 Form available at: hitpviahoa B. Board Members and Officers of Management Company L- TLE FULLNAME, PERSONAL OR BuSWESS ApDRESS | “NUMBER * InTeRe P Director/CEO . President ; Vice President . Secretary ; . [ Treasurer - , Other: : C. Voluntary Board Members and Officers of Management Company If the management company ls a not-for-profit corporation/organization, provide the requested information for each individual that SOrVOS as a voluntary board member. Attach additional sheets if necessary. FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER F 5. Required Disclosure The following disclosures are required: A. Pursuant to subsection 408,809(1)(d), F.S., the applicant shall submit to the agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(5), F.S., for each controlling interest. Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to subsection 408.809(1)(d), Florida Statutes? (These offenses are listed on the it of liance with B nd Screeni Requirements, AHCA Form 48100-0008.) Yes [J NO If yes, enclose the following information: : (2) The full tegat name of the individual and the position held LA description/explanation of the conwiction(s) - If the individual has received an exemption from disqualification for the offense, include a copy B. Pursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of any exclusions, Suspensions, or terminations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CLIA) programs, Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, Eyes terminated or involun } withdrawn from participation in Medicare or Medicaid in any state? YEs [] NO REC FIVE y Iyes, enclose the following information: (C2 The full legal name of the individual and the position held JAN 0 4 2012 OA description/explanation of the exclusion, suspension, termination or involuntary withdrawal, : Central Systems Management Unt AHCA Form 3110-1008, Revieed August 201 Section 59A-35,060(1), Florida Administrative Cogs Page 6 of 8 Form available st: http/ahca.myftorida.com/Pubt § . , C. Pursuant Won 408.815(4), F.S., does the applicant or any Controlling interest in an applicant have any of the: following: vEs(] no Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 617, chapter 893, 21 U.S.C. $s. 801-970, or 42 U.S.C. ss. 1385-1396, within the previous 15 years prior to the date of this application: YEs([ No CY Terminated for cause from the Florida Medicaid program pursuant to s. 409.013, and not been in goog standing with the Florida Medicaid program for the most recent § years, yYes—[] No Terminated for cause, pursuant fo the appeals procedures established by the state or federal government, from the federal Medicare program or from any other state Medicaid program, have not been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and tha termination was tess than 20 years prior to the date of this application. 6. Provider Fines and Financial Information A RNa, Pursuant to subsection 408.831 (1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or & Jicansee which shares a common controlling interest with the applicant if they have falled to pay all outstanding fines, liens, or ove Nents assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless @ repayment plan is approved by the agency, Are there any incidences of outstanding fines, liens or overpaymenis as described above? YES [] NO wo If yes, please complete the following for each incidence (attach additiorial sheets if necessary): Amount: $ assessed by: [7] Agency for Health Care: Administration Case # —_—- C]. cus Date of related inspection, application or overpayment period if applicable: _. Oue date of payment: Is there an appeal pending from a Final Order? Yes No Please attach a copy of the approved repayment plan if appilcable. 7. _ Other Program Specific information , teense Please provide the following information for the requested positions: A.. Does the owner, administ , OF any facility representative serve as “representative payee” or as power of attorney for any ALF residents? [] YES NO Representative Payee is an Individual or entity who receives payments on behalf of a resident (1.8. social security benefits, Supplemental social security or optional state supplementation), A resident must give consent for an owner, administrator or fectity representative to act as thelr Tepresentative payee or power of altorney, If yes, section 429.27(2), F.S., states that you must obtain a surety bond or continuum bond from a licensed su Y raty company. Has a surety or continuum bond been obtained? Es [] NO Please attach a copy. B. Is the ALF a part of a continuing care retirement community (CCRC) pursuant to Chapter 651,F.8.2 (] Yes [fio If yes, attach @ copy of your Certificate of Authority with the initial or change of ownership application. ©. Does the ALF participate in a Medicaid Waiver program? YES [JNO Ifyes, please provide number: usa Sato REGEWED JAN 04 2012 . Central Systems Management Unit AHCA Form 3110-1008, Revised August 2011 Page 7 of 8 ‘ Section 59A-35.080(1), Florida Administrative Coda abes ida /P SuOne/F orms/HQA shit WHOA shit 8. Affidavit \, LC hereby swear or affirm, under penalty of perjury, that the statements in this application are true and correct. As administrator or authorized representative of the above named Provider/facility, | hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum - standards of sections 435.04, and 408,809(5), Florida Statutes (F.S.) or are awaiting screening results. In addition, | attest that all employees subject to Level 2 screening standards have attested to meeting the requirements for qualifying for employment and agree to inform me immediately if convicted of any of the disqualifying offenses while employed here as specified in subsection 435.04(5), F.S, : CLOULL Pohain yer 4 1.02/30] Signature of Li or Authorized’ Representative Title RETURN THIS COMPLETED FORM WITH FEES AND ALL REQUIRED : DOCUMENTS TO: | AGENCY FOR HEALTH CARE ADMINISTRATION ASSISTED LIVING UNIT . 2727 MAHAN DR., MS 30 TALLAHASSEE FL 32308-5407 Questions? Review the information availatile at: RECEIVED JAN 0 4 2012 Central Systems Management Unii AHCA Form 3110-1008, Revised August 2011 Section 59A-35.060(1), Florida Administrative Code Page 8 of 8 ida Publications/Forms/HOA.s ance. .myitorid Form available at: http Contitied Fee Return Recelpt fee Postmark (Endorsement feduited) Here Restrloted Delivery Fea (Endoraement Regier} 7011 1570 oo00 3003 O4ngo COMPLETE THIS SECTION ON DELIVERY Raine AACELEN q ‘egalyed by (fYinted Namal 'C. Date of Delivery byw £1312 i item 1? 0 Yes dress below: [1 No , SENDER: COMPLETE THIS SECTION i Complete Items 1, 2, and 3, Also complete item 4 if Restricted Delivery Is desired. ™ 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 maliplece, { or on the front if space permits. 1, Article Addressed to: D Agent D Addressee if YES, enter delivery al Racwret Par cocd/ ESB WO Vom M On YS re KIO Ot hs 3 Sepia Type Certifled Mall [1 Express Mall T] Registered C1 Return Recelpt for Merchandise Haduison VW CO Insured Mail 1.6.0.0. 4, Restricted Dalivery? (Extra Fee) O Yes 7OLL L570 OO00 3003 gyno OU renererrem-corres recy la rn perenne y i PS Form 3811, February 2004 Domestic Return Receipt 402595-02-M-1840

Docket for Case No: 12-000440