red. 19, 2013 11:43AM FL Builders Appliance Sarasota No 5211 PL 1/43 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. AHCA No. 201201278] DULCE HOGAR, INC,, 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, Dulce Hogar, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. PARTIES 1, The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Ch. 408, Part IL, Ch, 429, Part I, Fla. Stat. (2012); Ch. 584-5, Fla. Admin. Code, The Agency may deny, revoke, and suspend any license issued to an assisted living facility and inspose an adnainistrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla, Stat. (2012). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency feb. 15. 2013 1t:43AM = FL Builders Appliance Sarasota No. 5211 P, 2/43 may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2012). 2. The Respondent was issued a license by the Agency to operate an assisted living facility located at 423 West 12th Place, Hialeah, Florida 33010 (“the Facility”), and was at al] times material required to comply with the applicable statutes and rules governing assisted living facilities. Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who are unable to live independently. These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Assisted living facilities are regulated in a manner so as to encourage dignity, individuality, and choice for residents, while providing them a reasonable assurance for their health, safety and welfare. Generally, assisted living facilities provide supervision, assistance with personal care and supportive services, as well as assistance with, or administration of, medications to residents who require such services. COUNT I Terminated For Cause From State Medicaid Program 3. Under Florida law, in addition to the grounds provided in authorizing statutes, gxounds 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: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)(e), Fla. Stat. (2012). 4. On November 5, 2012; the Agency terminated Leo Homes, Inc. for cause from the state Medicaid program by way of Final Order issued by the Agency in Case No. Cl Feb. 15. 2013 11:43AM FL Builders Appliance Sarasota No. 5211 =P, 3/13 430301000, Provider Number 006277700. 5. Leonard Sifredo is a controlling interest in Leo Homes, Inc. 6. Leonard Sifredo is a controlling interest in Dulce Hogar, Inc. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, tespectfully intends to enter a final order granting the following relief: 1 Make findings of fact and conclusions of law in favor of the Agency, 2. Impose the relief against the Respondent as set forth above. Respectfully submitted on this 4th day of February, 2013. Florida Bar No, 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, M83 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com, NOTICE The Respondent is notified of the right to request an administrative hearing pursuant to Sections 120,569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it has the right to be represented by an attorney in this matter at its own expense, Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Admjnistrative Complaint, a final order will be entered. Feb. 15.. 2013 14:43AM — FL Builders Appliance Sarasota No 521) PL 4/43 PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes, Tt must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. ‘The request for formal hearing must conform to the requizements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attomey or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate, 4. A statement of when the respondent received notice of the administrative complaint, 5. A statement including the file number to the administrative complaint, Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, Licensee Name: Contact Person: Title: a ee Address: ‘Number and. Street City Zip Code Telephone No. _ Fax No. E-Mail (optional) Thereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name; _ Title: Feb. 15. 2013 1f:44AM FL Builders Appliance Sarasota. No. 5211 P. 12/13 Fig AGENCY CLERK STATE OF FLORIDA , 2013 F AGENCY FOR HEALTH CARE ADMINISTRATION BB 2b Ali iy Re: DULCE HOGAR IL, INC. : AHCA No. 2012012781 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency 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 4 Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Hasiern Time, of the day that you recaive the attached proposed agency action. If your Khection of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued, Please use this form unless you, your attorney or your representative prefer to reply according to Chapteri20, Florida Statutes, and Chapter 28, Florida Administrative Code.) . Please retum your Election of Rights to this address: Agency for Health Care Administration Attention: Ageney Clerk : 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone; 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) ___I admit to the allegations of facts and Jaw céntained in the Notice of Intent to Lopose a Late Fee, Notice of Intent to Impose a Late Fine, 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 oraction, OPTION TWO (2)__T admit to the allegations of facti contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (puravant to Section 120.57(2), Florida Statutes) where 1 may submit testimony and written evidence to the Agency to show that the proposer! administrative action is too severe or that the fine should be reduced. OPTION THREE owt dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request 4 formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Heatings. Feb, 26, 2013 11:28AM | FL Buitders Appliance Sarasota . No. 522) 7/7 ' PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain, a formal hearing before 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 agency 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. ‘The name, address, telephone number, and facsimile number (if any) of the Respondent. . 2. The name, address, telephone number and facsimile umber of the attomey or qualified representative of the Respondent (if any} upon whom service of pleadings and other papers shall bemade, : ‘ : . 3. A statement requesting an, administrative heating identifying those material facts that are in dispute. If there are none, the petition must so indicate. = : . 4. A statement of when the respondent received notice of the administrative complaint. "5. A statement including the file number to the administrative complaint. | Mediation under Section 120.573, Florida, Statutes, may be' available in this matter if the Agency agrees. ; , Licensee Name: he “ ontat Peron: (er “nite; TV.CNC, COC, CPCO mths. erate sete ? aires: 2333 Prmbell Ave. Ste Al, Mirus Fl. 33/29 City » Number and Street Zip Code — TaeponeNo, BOS™ 35K 4SIO pax No. BOS 35-3 - | E-Mail (optional) COaT Te (lo@ vitalehen (4 laws Cor I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on mp) of the licensee referred to above, Sioned: Date: 225- (fo Printed Name: ( by ler ‘ Title: Ty,cHe,¢ PCCPCO GHA Mohen Ayr Quali. ep. w Upon jecemt oF Notice STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, \ . . . ; AHCA No. 2012012781 DULCE HOGAR, INC., 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, Dulce Hogar, Inc, (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Ch. 408, Part I, Ch. 429, Part I, Fla. Stat. (2012); Ch. 58A-5, Fla. Admin, Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Cate Licensing Proceduyes Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat, (2012). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2012). 2. The Respondent was issued a license by the Agency to operate an assisted living facility located at 423 West 12th Place, Hialeah, Florida 33010 (“the Facility”), and was at all times material required to comply with the applicable statutes and rules governing assisted. living facilities. Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who aré unable to live independently, ‘These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Assisted living facilities are regulated in a manner so as to encourage dignity, individuality, and choice for residents, while-providing them a reasonable assurance for their health, safety and welfare. Generally, assisted living facilities provide supervision, assistance with personal care and supportive services, as well as assistance with, or administration of, medications to residents who require such services. COUNT Terminated For Cause From State Medicaid Program 3. Under 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: ... (e) The applicant, Licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)(e), Fla. Stat. (2012). 4, On November 5, 2012, the Agency terminated Leo Homies, Inc. for cause from the state Medicaid program by way of Final Order issued by the Agency in Case No. CI 130301000, Provider Number 006277700. 5. Leonard Sifredo is a controlling interest in Leo Homes, Inc. «6. Leonard Sifredo is a controlling interest in Dulce Hogar, Inc. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose the relief against the Respondent as set forth above. Respectfully submitted on this 4th day of February, 2013. Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John. Bradley@ahca,myflorida.com NOTICE The Respondent is notified of the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it has the right to be represented by an attorney in this matter at its own expense, Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days 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 delivered 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 I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights were served on the persons below on this 4th day of February, 2013. E. Bradley ssistant General Cousél Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John. Bradley@ahca.myflorida.com, Copies: Leonor Sifredo, Administrator/ Shaddrick Haston, Unit Manager Registered Agent | (Electronic Mail) : 423 West 12th Place Dulce Hogar, Inc. Hialeah, Florida 33010 Certified Mail - 7008 1300 0000 6174 2876 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: DULCE HOGAR, INC. AHCA No. 2012012781 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency 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 may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency 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] 20, Florida Statutes, and Chapter 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 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 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 Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing, | 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, 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) I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before 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 agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute, If there are none, the petition must so indicate, 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, Licensee Name: Contact Person: : Title: Address: ‘Number and Street : City . Zip Code Telephone No. . _ Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: NDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ‘@ Complete items 1;-2, and.3, Also complete item 4 if Restricted Delivery is desired, im Print your.name and address on the reverse so that we can return the card to you, M Attach this card to the back of the mailpiece, Or on the front If space permits, 1. Article Addressed to: Leonor Sifredo; ‘Administrator/ Registered Agent 1423: West 12th Place | (Dulce Hogar, Inc, (Wialagh '\Rlavida 2201Nn braraoh FC 3300) | | 3.,Sepice Type ‘Gone Mall (©) Express Mall? Registered D Retum Receipt for Merchandise O InsuredMal ~=01.0.0, 4. Restricted Delivery? (Extra Fea) Yes 2 Article Number, | eT (Teanstor from service lebey 7008 4300 oooo 6174 Pa?L | PS Form 381 1, February 2004 Domestic Return Recelpt 102595-02-M-1540. i] Postage Cortitled Feo Postmark Return Recelpt Feo Hore (Endorsement Required) Rlestricted Delivery Fee (Endorsement Required) Total Postage & Fees 7008 1300 OO00 6174 2876

Docket for Case No: 13-001839