STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012008303 Return Receipt Requested: v. 7009 0080 0000 0585 9746 AFFORDABLE HELPERS HOME CARE LLC, 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 Affordable Helpers Home Care LLC (hereinafter “Affordable Helpers Home Care LLC”), pursuant to Chapter 400, Part III, Chapter 408, Part II, and Section 120.60, Florida Statutes (2012), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $3,000.00 pursuant to Section 400.512, Florida Statutes (2012) and Section 400.474, Florida Statutes, for the protection of public health, safety and welfare JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and Chapter 28-106, Florida Administrative Code (2012). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2012). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing homemaker companion services pursuant to Chapter 400, Part III, Chapter 408, Part II, Florida Statutes (2012), and Chapter 58A-5 Florida Administrative Code (2012). 5. Affordable Helpers Home Care LLC operates a homemakers and companion services located at 8219 S. W. 51°* Street, Davie, Florida 33328. Affordable Helpers Home Care LLC is licensed as a homemaker companion service under license number 231374. Affordable Helpers Home Care LLC 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 I AFFORDABLE HELPERS HOME CARE LLC FAILED TO NOTIFY AHCA OF CHANGE OF ADDRESS PRIOR TO RELOCATION TO CURRENT LOCATION. RULE 59A~35.040, FLORIDA ADMINISTRATIVE CODE (CHANGE OF ADDRESS STANDARDS) UNCLASSIFIED VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Affordable Helpers Home Care LLC was cited with ‘two (2) unclassified deficiencies as the result of a complaint investigation survey that was conducted on July 3, 2012. 8. A complaint investigation survey was conducted on July 3, 2012. Based on interview and record review, it was determined that the HCS (Homemaker Companion Service) failed to notify AHCA (Agency for Health Care Administration) of a change of address, prior to their relocation to their current location, as required. The findings include the following. 9. At approximately 10:20 AM on 07/02/12, interview with the Owner of the HCS revealed that the HCS's office was no longer located at the address documented on their State Registration; had moved to another location and the HCS's Owner further stated that the HCS's new office location address had been reported to AHCA, "last week." 10. Review of documentation reveals that the HCS is currently registered as an HCS at a location that is not the HCS's current location. 11. Interview, at 11:00 AM on 07/02/12 with the HCS's Office Manager at the HCS's current office location revealed that the notice, informing AHCA of the new HCS's office address, | had not been sent yet. 12. Based on the foregoing facts, Affordable Helpers Home Care LLC violated Section Rule 59A-35.040, Florida Administrative Code, an unclassified violation, which warrants an assessed fine of $500.00. COUNT ITI AFFORDABLE HELPERS HOME CARE LLC FAILED TO CONDUCT THE MANDATED BACKGROUND SCREENING FOR PERSONNEL WHO ACTIVELY PROVIDE SERVICES TO CLIENTS. SECTION 408.809, FLORIDA STATUTES SECTION 435.02(2), FLORIDA STATUTES SECTION 435.06, FLORIDA STATUTES (BACKGROUND SCREENING STANDARDS) UNCLASSIFIED VIOLATION 13. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14, A complaint investigation survey was conducted on July 3, 2012. Based on record review and interview, it was determined that the HCS (Homemaker Companion Service) failed to conduct the mandated Background Screening for 5 of 6 sampled HCS personnel (Personnel #1, #3, #4, #5, and #6) who actively provide services to 4 of 4 sampled clients, Client #1, #2, #3 and #4, in the client's homes. The findings include the following. 15. Review of the records for the HCS's Personnel #1, #3, #4, #5, and. #6, who actively provide services to the HCS's clients, Client #1, #2, #3, and #4 in their homes revealed no evidence of documentation of Background Screenings. Further review revealed evidence of documentation that Personnel #1's date of hire with the HCS was 02/16/11. Personnel #3's date of hire with the HCS was 11/21/11. Personnel #4's date of hire, with the HCS was 05/06/10. Personnel #5's date of -hire with the HCS was 09/29/09, and Personnel #6's date of hire with the HCS was 10/16/09. 16. During an interview on 07/02/12 at approximately 1:00 PM, the HCS's Office Manager could not explain the lack of evidence of documentation of Background Screenings for the HSC's personnel. 17. Based on the foregoing facts, Affordable Helpers Home Care LLC violated Section 408.809, Florida Statutes, Section 435.02(2), Florida Statutes, Section 435.06, Florida Statutes, an unclassified violation, which warrants an assessed fine of $2,500.00 [$500.00 per incident x 5 incidents]. 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 Affordable Helpers Home Care LLC on Counts I and II. 2. Assess an administrative fine of $3,000.00 against Affordable Helpers Home Care LLC on Counts I and II for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is Just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2012). 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 Qbbas DN. Alba M. Rodkiguez, q. Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 5374 Street Suite 300 Miami, Florida 33166 305-718-5911 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. 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 Divya Girnar, Administrator, Affordable Helpers Home Care LLC, 8219 S. W. 51%* Street, David, Florida 33328 on this 13 day of Quo , 2013. Alba M. 2, Macatee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Affordable Helpers Home Care LLC AHCA No.: 2012008303 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: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) 1 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)__—S_—_I 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 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 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) I hereby 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 U.S: Postal Service ‘ta CERTIFIED MAIL: RECEIPT (Domestic Mail Only; No Insurance Coverage. Provided) HIS SECTION COMPLETE THIS SECTION ON DELIVERY Fordelivery information Visit our website al www.usps.comiy.. OFFICIAL USE Postage rifled Fee Fetur/#Recelpt Feo Postmark {Endorsem¢ht Required) Reatricted Delivery Foo (Endorsement Required). Total Postage & Feas orPO Box No. PANG... CI . Lia 6 PS Form $800, August-2006 Sy4 7005 0086 cOO0 0585 4b pie

Docket for Case No: 13-003366