STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No.: 2012007532 vs. ANDRADA SUNSHINE CORPORATION d/b/a GOOD SAMARITAN RETIREMENT HOME, ’ Respondent. ee ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (the “Agency”) and files this administrative complaint against » Andrada Sunshine Corporation d/b/a Good Samaritan Retirement Home, (“Respondent” or “Respondent Facility”), pursuant to §§ 120.569, and 120.57, Fla. Stat., and alleges: NATURE OF THE ACTION This is an action to revoke the license of an assisted living facility, to impose an administrative fine in the amount of two thousand dollars ($2,000.00), a survey fee of five hundred dollars ($500.00) and for such other relief as this tribunal may determine, pursuant to Chapters 408, Part II, and 429, Part I, Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapters 408, Part II, and 429, Page 1 of 21 Filed August 22, 2012 3:08 PM Division of Administrative Hearings Part I, 2, 3. Florida Statutes. Venue lies pursuant to Fla. Admin. Code R. 28-106.207, PARTIES The Agency licenses all assisted living facilities and enforces all applicable Florida statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter Florida 4, located 429, Part I, Florida Statutes, and Chapter 58A-5, Administrative Code. Respondent operates a 65-bed: assisted living facility at 507 S.E. lst Avenue, Williston, Florida 32696, and is licensed as an assisted living facility, license number 25, 5. At all times material to this complaint, Respondent was licensed by the Agency and was required to comply with all applicable rules and statutes. 6. Section 408.815, Florida Statutes, provides: (1) 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. (b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c) A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid Page 2 of 21 program, the Medicaid program of any other state, or the Medicare program. 7. Section 429.14, Florida Statutes, provides: (1) In addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any | , provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or -for the actions of any facility employee: (a) An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. (b) . (Cc) Misappropriation or conversion of the property of a resident of the facility. (a)... ; : (e) A citation of any of the following déficiencies as specified in s. 429,19; ; 1. One or more cited class I deficiencies. 2. Three or more cited class II deficiencies. 8. An Immediate Moratorium on Admissions, Agency VERSA number 2012005625, was imposed on’ Respondent on May 22, 2012. COUNT I_A025 9. The Agency re-alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 10. Rule 58A-5,0182, Florida Administrative Code, requires: 58A-5.0182 Resident Care Standards. : An assisted living facility shall provide care and services appropriate to the needs. of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for éach resident, Page 3 of 21 including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule S8A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical ‘and emotional well-being of the individual, (c) General awareness of the resident's whereabouts, The resident may travel independently in the community. (ad) Contacting the resident’s health care provider and other appropriate party such as the resident's family, guardian, health care Surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case Manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-~ 5.0131(33), P.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes .Which resulted in the provision of additional services. (3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate resident access to needed health care, the facility shall, as needed by each resident: (a) Assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. (6) Provide transportation to needed medical, dental, nursing or mental health services, or arrange for transportation through family and friends, volunteers, taxi cabs, public buses, and agencies providing transportation for persons with disabilities. (c) The facility may not require residents to see a particular health care provider, 11. Rule 58A-5.020, Florida Administrative Code, requires: (1) GENERAL RESPONSIBILITIES. When food service is provided by the facility, the administrator ora Person designated in writing by the administrator Shall: (a) Be responsible for total food Services and the day to day supervision of food services staff. (6) Perform his/her duties in a safe and sanitary Manner, Page 4 of 21 (c) Provide regular meals which meet the nutritional needs of residents, and therapeutic diets as ordered by the resident’s health care provider for resident's who require special diets. (2) DIETARY STANDARDS. (e) Therapeutic diets shall be prepared and served as ordered by the health care provider. oo 1. Facilities that offer residents a variety of food choices through a select menu, buffet style dining or family style dining are not required to document what is eaten unless a health care provider's order indicates that such monitoring is necessary. However, the food items which enable residents to comply with the therapeutic diet shall be identified on the menus developed for use in the facility. : . 2. The facility ‘shall document a resident’s refusal to comply with a therapeutic diet and notification to the resident’s health care provider of such refusal. If a resident refuses to follow a therapeutic diet after the benefits are explained, a signed statement from the resident or the resident's responsible party refusing the diet is acceptable documentation of a resident's preferences..In such instances daily documentation is not necessary. : 12. On November 30 and December 1, 2011, the Agency conducted a complaint investigation survey of the Respondent. 13. Based on the Agency’s surveyor’ s interviews, review of Respondent’s records and observations, the Agency concluded that the Respondent failed to meet the medical needs of one resident, Resident #1, of the two residents whose care was reviewed by the Agency’s surveyor. 14. On November 30, 2011, at 1:00 p.m., the Agency's surveyor conducted an interview with Respondent’s administrator. Respondent’s administrator stated that no podiatrist is Page 5 of 21 ' scheduled to come to the facility. Residents have-not been seen by a podiatrist in an unknown amount of time. 15. The Agency’ 8 surveyor’s review of Respondent's records for Resident #1 revealed that Resident #1 was seen by her physician on 7-18-2011 and again on 11-14-2011, and an order was given each time for Resident #1 to be seen by a podiatrist within a week and for blood pressure monitoring, 16. However, Respondent did not assist Resident #1 in making an appointment until a third order was received, A referral on 12~6-2011 to a podiatrist was made by a member of Respondent’ s staff for Resident #1 after Resident #1’s physician gave a third order on 11-21-2011, 17. Respondent had no documentation for blood pressure monitoring for Resident #1’s blood pressure for the last six months prior to the Agency’s survey of November 30 and December 1, 2011, . 18. The Agency’s surveyor, who is a Registered Nurse, observed Resident #1 on 11-30-2011 at 1:30 PM, Resident's right great toe was red and swollen; the toenail appeared to be lifting away from the nail bed. 19. On 11-30-2011 at 1:30 PM, the Agency’ s surveyor interviewed Resident #1, Resident #1 stated that she had not been seen by a podiatrist, and that she has been having pain in her toe for several months, Page 6 of 21 20. The Agency determined that the Respondent’s above- described failure to provide care and services appropriate to the needs of Resident #1 is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents,-and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 21. The Agency conducted a complaint investigation survey of the Respondent on April 30, 2012. . 22. Based on the Agency’s surveyor'’s review of Respondent's records and on the Agency’s surveyor’s interviews, the Agency determined that the Respondent failed to properly supervise one (1) resident whose care by Respondent was reviewed and Respondent failed to investigate an injury to the resident of unknown origin. 23. The Agency’s surveyor’s review of Respondent's incident log reveals a report for Resident #1 dated 4/11/12 which indicates the resident had multiple bruises on her hands and two bruises on her legs. 24. The Agency’s Surveyor’s review of a Hospice note for Resident #1 dated 4/10/12 indicates bruising on her wrist. A second Hospice note dated 4/12/12 indicates that bruising was Page 7 of 21 noted on the resident's arms. All notes indicate bruising of unknown origin. 25. In an interview with employee "E" on 4/30/12 at 9:45 PM, employee “EM stated that only general observations of the ‘resident were performed, and that no formal investigation or documentation was performed. Respondent’ s staff Made no determination of how the injuries occurred to Resident #1. Employee Re stated that Resident #1 was moved into a private room after the discovery of the first bruising, in case there had been any involvement of the: roommate. Employee “E” told the Agency’s surveyor that the bruising is now healed. 26. The Agency determined that the Respondent’s above- described failure to provide care and services appropriate to the needs of Resident #1 is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation. for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 27. The Agency conducted an unannounced monitoring survey of the Respondent’s assisted living facility on May 17 through 20, 2012, 28, Based on the Agency's surveyors’ review of Page 8 of 21 Respondent’s records, observations and interviews, the Agency concluded that the Respondent facility failed to monitor the quantity and quality of resident’s diets and failed to provide therapeutic diets in accord with health care provider’s orders for eight (8) - Residents #1, #2, #11, #12,.#23, #25, #26, and #29 - of the forty-two (42) residents whose care was reviewed by the Agency’s surveyors. 29. The Agency's surveyors’ review of Respondent’s records for Resident #1 found that Resident #1 was admitted to the Respondent’s facility on 8/23/2011. Resident #1 was re-admitted to the facility from the hospital on 12/19/2011. Diagnoses included hypertension, diabetes, bi-polar disorder, coronary artery disease, and stroke with left side weakness. 29.a. Resident. #1 was ordered to be on a No Concentrated Sweets, No Added Salt diet with Pureed consistency per physician order dated 10/14/2011 as noted on Resident Health Assessment ‘(AHCA form 1823). 29.b. The Agency’s surveyor’s review of Respondent’s records for Resident #1 found a Resident observation Log ‘entry dated 1/29/2012 stating that Resident #1 was observed to be choking in the dining room during lunch time. Heimlich maneuver was performed on Resident #1 and pieces of meat came out. Further record review revealed another Resident Observation Log entry dated 1/30/2012. which stated Page 9 of 21 that the Respondent received a call from the hospital advising that Resident #1 has passed away. The Agency’s surveyors’ review of Resident #1's Florida Certificate of Death revealed that the resident's cause of death was aspiration. 29.c. “Aspiration” refers to the accidental sucking in of food particles or fluids into the lungs. ‘29.d. On 5/17/2012 at 1:20 PM, the Agency’s surveyor conducted an interview with Respondent’s Med Tech. The Med Tech stated to the Agency’s surveyor that she was present in the dining room on 1/29/2012. She heard Resident #1 cry out and noticed his hand was holding his throat, and he was spitting out meat. Respondent’s Certified Nursing Assistant (“CNA”) checked resident #1's mouth and saw more meat. She called out for 911 to be called and did the Heimlich maneuver 3 times. Resident #1 lost consciousness, An ambulance arrived, and the paramedics opened Resident #1’s airway, but the resident did not regain. consciousness, An ambulance took Resident #1 to the hospital. She stated that Resident #1 was eating sliced beef. 29.e. On 5/17/2012 at 2:00 PM, the Agency’s surveyor conducted an interview with Respondent ’s Administrator. Respondent’s administrator admitted to the Agency's surveyor that that Resident #1 was eating regular Page 10 of 21 consistency food on 1/29/2012, when Resident #1 began choking on the meat he was eating. The Administrator stated to the Agency’s surveyor that the food given to Resident #1 was not of a pureed consistency because Resident #1 was never on a pureed diet since he did not have any problems eating. The Administrator was not aware that Respondent’ s records for Resident #1 contained a physician's order for a pureed consistency diet to be given to Resident #1. Respondent’s Administrator stated meat is now tenderized longer. 29.f. On 5/18/2012.at 10:00 AM, the Agency’s surveyor interviewed the primary physician for Resident #1. The physician told the Agency's surveyor that he had not changed the diet consistency order for Resident #1. ‘The , physician stated that the order from 10/14/2011 for pureed consistency diet was still to be followed, as he had not changed the order to a regular consistency. 30. The Agency’s surveyors’ review of Resident #2's record revealed that Resident #2’s most recent health assessment was dated 9/26/2011. The resident has. listed medical diagnosis of diabetes, hypertension, GERD, Vitamin B12 deficient, Urinary incontinence and COPD. Further review of the health assessment revealed that the resident was to be on a Diabetic Diet. 30.a. A Diabetic Diet is generally characterized by a Page 11 of 21 diet which is high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especially Saturated fat. 30.b. The Agency’s surveyors’ further review of Respondent’ s records for Resident #2 found a record of Resident #2’s hospitalization. Resident #2's hospital discharge instructions dated 01/02/2012 stated that the resident was discharged with orders requiring: "Custom diet at discharge. Mechanical soft." Further review of the hospital record revealed the section entitled "Hospital Course. Review of this section revealed, "A [computed tomography] CT of the chest was done and appeared to show chronic aspiration pneumonia." The end of this section stated, "She will remain on the mechanical soft diet as recommended by the speech therapist who performed the swallow evaluation." Further review of the resident's tecord failed to reveal an up-dated health assessment completed after Resident #2's significant change in condition which required Resident #2 to now have a mechanical soft diet. 30.c. A mechanical soft diet may be prescribed for patients who have difficulty chewing or swallowing. The foods recommended are chopped, ground, or blenderized and prepared with added liquids to make them easier for the Page 12 of 21 patient to eat. 30.d. ‘The Agency’s surveyor observed Resident #2 on 05/18/2012 .at 5:15 PM, during the evening meal. Rather than the required mechanical soft diet, Resident #2 was eating a salad that consisted of lettuce, cucumber cut in quarters, tomatoes, 1/4 slice of egg, 3 long strips of chicken, and 4 Saltine crackers. ‘The Agency’s surveyor observed members of Respondent's staff place the salad in front of the resident, and then walk away. No one. cut the chicken strips or the egg for the resident. After everyone was served the salad, a member of Respondent’s staff put a cup of watermelon cut in large chunks next to Resident #2. 30.e. The Agency's surveyor again observed Resident #2 on 05/20/2012 at 11:52 AM, during Respondent’s lunch time meal. Again, members of Respondent's staff served Resident #2 a regular meal. The lunch consisted of a thick piece of. meatloaf, half.a baked potato, and mixed vegetables. A member of Respondent’s staff was observed putting butter on Resident #2's baked potato and then walking away. At 12:01 PM, Resident #2 was observed to have eaten only the middle of the baked potato - the area without butter was not touched - and about 1/4 of her meatloaf. Once again, all residents, including Resident #2, were served large chunks of watermelon with her meal. Resident #2 left the Page 13 of 21 remainder of her lunch on the plate, putting her napkin over it. No member of Respondent’s staff talked to Resident #2 about the meal. 30.f. The Agency’s surveyor also observed that Resident #2 did not eat her dinner on 05/20/2012. No member of: Respondent's staff appeared to notice that Resident #2 had not eaten. 30.9. The Agency’s surveyors interviewed the Respondent's Administrator on 05/18/2012 at 4:45 PM. The Administrator told the Agency’s surveyors that he was not sure why no one caught the change in diet order for Resident #2. 31. The Agency’s surveyor reviewed Resident #11's record and found a health assessment dated 04/11/2012, which stated that the resident was to have a pureed diet. . 31.a. Review of Resident #11's health assessment dated 9/20/2011 revealed the resident was to be on a calorie controlled and pureed diet. 31.b. Review of the Medical Certification for Nursing Facility Home and Communi ty Based Services Form revealed it was filled’out by the facility staff. Further review of this document revealed the staff checked that the resident required a pureed diet. ! 32. The Agency’s surveyor reviewed Respondent’s records Page 14 of 21 for Resident #12. 32.a. Respondent's records’ revealed that Resident #12 had a health assessment dated 3/28/2012. Further review of the health assessment’ revealed that the resident is to be on a 2,000 calorie and ADA, diabetic, diet. 32.6. Review of a prior health assessment, dated 12/26/2011, revealed that Resident #12 was to be on a 2,000 calorie and ADA diet. 32.¢c, However, when the Agency’ s surveyor reviewed a list of residents provided to the Agency's surveyor by the Respondent listing. each resident receiving a diabetic diet, the list did not include Resident #12's name, 33. The Agency’s surveyor’s review of Resident #23's record revealed a health assessment dated 08/15/2011. Review of this health assessment revealed that the resident was to be on a 2,000 calorie, diabetic diet. However, the Agency’s surveyor’s review of the facility's list of people on diabetic diets did not reveal Resident #23's name. 34. The Agency’s surveyor’s review of Resident #25's record revealed a health assessment dated 05/13/2010... The health assessment indicated that the resident is to be on a mechanical soft diet. Review of Resident #25's Resident Observation Log revealed the resident is under HOSPICE care. 35. The Agency’s surveyor reviewed Respondent’s records Page 15 of 21 for Resident #26. Resident #26's record contains a health assessment dated 10/31/2011 which indicates the resident is on a regular, low fat/low cholesterol diet with no concentrated sweets. However, the Respondent's list of residents on a diabetic diet included Resident #26's name. 36. Review of resident 429's record revealed a health assessment dated 10/25/2011. Review of this health assessment revealed the resident was to be ona no-added-salt diet. 37, The Agency’s surveyors interviewed Respondent’ s food service staff regarding Respondent’s provision of therapeutic diets. On 5/17/2012 at 1:10 PM, the Agency’s surveyor conducted an interview with Respondent’ s Resident Caregiver and Kitchen . Aide, who has been at the Respondent’s facility since 2005. She stated that pureed or ground-up Food is offered if doctor orders are given for that type of food. On 05/18/2012 at 3:55 PM, the Agency’s surveyor requested Respondent’s cook to provide a list of all the specialty diets the facility is currently serving. The cook provided a list that only included 12 residents who were on diabetic diets. The cook was asked if there were any other special diets currently being served to residents, and she replied only diabetic ones. 38. Respondent violated Rules 58A-5.0182 and 58A-5.020, Florida Administrative Code, by failing to provide therapeutic diets as ordered by each Resident’s health care provider. Page 16 of 21 Specifically, Resident #1 was not given a pureed diet and died of aspiration, sucking in of food particles into the lungs; Resident #2 was not given a mechanical soft diet; Resident #11 was not given a pureed diet; Resident #12 was not on the: list to receive a diabetic diet, and there was no provision to Limit caloric intake to 2,000 calories; Resident #23 was not on the list to receive a diabetic diet, and there was no provision to limit caloric intake to 2,000 calories; Resident #25 was not - given a mechanical soft diet; Resident #26 was given a diabetic diet instead of the ordered low fat/low cholesterol diet with no. concentrated sweets; and there was no provision for Resident #29 to be given a no-salt~added diet. . 39. The Agency determined that the above violations as found at the May 17 through 20, 2012, Agency survey are each conditions or occurrences related to the operation and maintenance of a provider or to the care of residents each of which the agency determined presents an imminent danger to the residents of the provider or 4 substantial probability that death or serious physical or emotional harm would result from the violations, and each of which the Agency determines to be a class I violation for purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes, WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00 against Respondent, an assisted Page 17 of 21 living facility in the State of Florida, for the above-described class II violations found at the April 30, 2012, Agency survey, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this’ tribunal deems just. COUNT II REVOCATION 40. The Agency re-alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 41. Counts I shows a demonstrated pattern of deficient performance for purposes of. § 408.815(1) (da), Florida statutes, warranting revocation of Respondent’s license. 42. Count I is a violation of this part, authorizing statutes, or applicable rules, for purposes of § 408.815(1) (c), Florida Statutes. 43, The violations set forth in Count I are an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility, for purposes of §§ 408.815(1) (b) and 429.14(1) (a), Florida Statutes, each warranting revocation of Respondent’s license. 44, Each of paragraphs 41 through 43 are a separate and distinct ground for revocation of Respondent's license as an assisted living facility. . WHEREFORE, the Agency intends to revoke the license of Respondent, an assisted living facility in the State of Florida, pursuant to Chapters 408, Part II, and 429, Part I, Florida Page 18 of 21 Statutes, or such further relief as this tribunal deems just. COUNT IIT Survey Fee 45. The Agency re-alleges and incorporates paragraphs one (1) through eight (8) and Counts I, as if fully set forth in this count. . 46. Pursuant to Section 429.19(7), Florida Statutes, in addition to any administrative fines imposed, the Agency may assess a survey fee equal to the lesser of one half of a facility's biennial license and bed fee, or $500, to cover the cost of conducting an initial complaint investigation that results in the finding of a violation that was the subject of the complaint, or to cover the cost of a future monitoring survey where the current survey finds one or more Class I or Class II violations. 47. on or about April 30, 2012, the Agency conducted a complaint investigation at the Respondent Facility which resulted in the finding of a violation that was the subject of the complaint to the Agency, or which found one or more Class II violations, or both. 48. Pursuant to Section 429.19(7), Florida Statues, such a finding as specified in paragraph 47, above, subjects the Respondent Facility to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee, or $500.00. Page 19 of 21 49, Respondent is therefore subject to an additional survey fee of five hundred dollars ($500.00), pursuant to Section 429,.19(7), Florida Statutes, in addition to the fine applicable to the violations found. WHEREFORE, the Agency intends additionally to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(7), Florida Statutes. NOTICE ‘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 #3, MS #3, | ' Tallahassee, FI, 32308, whose telephone number is 850-412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 ‘DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7012 1010 0000 5357 2996, to Miskel Ortiz, Administrator, 507 S.E. 1°%* Avenue, Williston, FL 32696, and by regular U.S. Mail to Gus R. Benitez, Esq., as attorney for Andrada Sunshine Corp., 1223 East Concord Street, Orlando, FL 32803, on July wd, 2012. Page 20 of 21 Asgistant General Counsel Fla. Bar. No. 817775 . Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727-552-1944 (office) 727-552-1440 (facsimile) e-mail: james.harris@ahca.myflorida.com Copies furnished to: . Anna Lopez, HFE Supervisor, Alachua Page 21 of 21 Copyright® 2042 (ISPS, all Rights Rosorved, U.S. Postal Service: CERTIFIED MAIL RECEIPT Coverage Provided) (Domestic Mail Only; No Insurance Postage | Certified Feo jy Recelpt Fee (endonement Raquited) Delivery Fee to (Cattment Required) goon 5357 256 4 71, Miskel Ortiz, Administrator ‘ru! 507SE. 1 Avenue ‘3° Williston, FL 32696 70 PS Form 3600, AUCs! 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Docket for Case No: 12-002842