STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2018006642 A DREAM LAKE MANOR, INC. d/b/a APOPKA RETIREMENT CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, A Dream Lake Manor, Inc. d/b/a Apopka Retirement Center (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine of $5,000.00 against the Respondent based upon one class [I violation. 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. (2017), Ch. S58A-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 Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2017). 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. (2017). 2. The Respondent was issued a license by the Agency to operate an assisted living facility (‘the Facility”) and was at all times material required to comply with the applicable statutes and rules governing assisted living facilities. COUNT I Safe Living Environment 3. Under Florida law, (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and, 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident, 2. A closet or wardrobe space for hanging clothes, 3. A dresser, chest or other furniture designed for storage of clothing or personal effects, 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and, 5. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. (d) Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be threadbare. Fla. Admin. Code R. 58A-5.023(3). 4. On or about December 28, 2017, the Agency conducted a survey of the Facility. 5. Based on record review and interview, the Facility failed to implement sufficient intervention to maintain an environment free of fire hazards for its residents. 6. A record review was conducted of the Facility’s records. Ts The Facility’s house rules stated that smoking is not allowed inside of the Facility. 8. On 12/28/17 at 9:26 AM, an interview was conducted with Resident #12. 9. Resident #12 stated that, approximately three weeks ago, someone smoked in a room, 10. Resident #12 stated that, at the same time, someone started a fire in a trash can. 11. Resident #12 stated that all of the residents were evacuated outside. 12. On 12/28/17 at 9:51 AM, an interview was conducted with the Facility’s Administrator. 13. The Administrator confirmed that there had been a fire at the Facility. 14. | The Administrator stated that the fire alarm went off. 15. The Administrator stated that she was unsure of the date of the fire. 16. The Administrator stated that she was unsure of the time of the fire. 17. The Administrator stated that she did not document anything regarding that incident. 18. The Administrator stated that the fire was located in a trashcan in the bathroom shared by Residents #7 and #10. 19. | The Administrator stated that both Resident #7 and Resident #10 deny starting the fire. 20. | The Administrator stated that Resident #10 is no longer at the Facility. 21. On 12/28/17 at 10:02 AM, an interview was conducted with Staff B. 22. Staff B is a caregiver at the Facility. 23. Staff B stated that he was at the Facility when the fire occurred. 24. Staff B stated that the fire alarm went off. 25. Staff B stated that the room of Resident #7 was filled with smoke. 26. Staff B stated that the room of Resident #10 was filled with smoke. 27. Staff B stated that he was unable to enter the bathroom due to the smoke. 28. Staff B stated that all of the Facility’s residents were evacuated outside. 29. Staff B stated that the fire department came to the Facility and put out the fire. 30. Staff B stated that all of the residents went back into the Facility, when the fire department left. 31. Staff B stated that he did not remember the time of the incident. 32. On 12/28/17 at 10:20 AM, an interview was conducted with the Administrator. 33. The Administrator stated that, after the fire, she instructed staff to check the rooms and bathrooms of residents who smoked for cigarette butts. 34. and then. 35. 36. 37. 38. 39. 40. 41. The Administrator stated that she instructed staff to perform this check every now The Administrator identified Resident #1 as a cigarette smoker. The Administrator identified Resident #2 as a cigarette smoker. The Administrator identified Resident #3 as a cigarette smoker. The Administrator identified Resident #4 as a cigarette smoker. The Administrator identified Resident #5 as a cigarette smoker. The Administrator identified Resident #6 as a cigarette smoker. The Administrator identified Resident #7 as a cigarette smoker. 42. The Administrator identified Resident #8 as a cigarette smoker. 43. The Administrator identified Resident #9 as a cigarette smoker. 44. The Administrator identified Resident #11 as a cigarette smoker. 45. The Administrator stated that she spoke with Resident #7 and said that if it happens again, they would have to leave the Facility. 46. The Administrator stated that she spoke with Resident #10 and said that if it happens again, they would have to leave the Facility. 47. The Administrator stated that she did not speak with any of the other residents who smoke because they already knew. 48. The Administrator did not provide any documentation to show that additional interventions were implemented to prevent another fire from occurring. 49. At 10:46 AM, the Administrator stated that she was unable to provide any documentation to show that the Facility had conducted fire drills, as required. 50. The Respondent’s actions, or inactions, constitute a class II violation. 51. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. § 408.813(2)(b), Fla. Stat. (2017). Sanction 52. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 53. Under Florida law, In addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living facility, for the actions of any person subject to level 2 background screening under s. 408.809, for the actions of any facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. § 429.19(1), Fla. Stat. (2017). 54. — Under Florida law, Each violation of Part I of Chapter 429 and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: Class “II” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks an order that: 1. Makes Findings of fact and conclusions of law in favor of the Agency. 2. Imposes sanctions against the Respondent as set forth above. Respectfully Submitted, Lylt S. D. Carlton Enfinger, IL/S¢ Florida Bar No. 793450 Maurice T. Boetger, Assistant General Counsel Florida Bar No. 0125192 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3658 Facsimile (850) 513-0616 Email: carlton.enfinger@ahca.myflorida.com NOTICE Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28-106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the individuals named below by the method designated on this Say of as 301 8. ike D. Carlton Enfinger, II, Sg Florida Bar No. 793450 Maurice T. Boetger, Assistant General Counsel Florida Bar No. 0125192 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3658 Facsimile (850) 513-0616 Email: carlton.enfinger@ahca.myflorida.com Administrator Apopka Retirement Center 750 South Alabama Ave. Apopka, Florida 32703 (Certified U.S. Mail) Apopka Retirement Center 1553 Danisco Place Apopka, Florida 32703 (Certified U.S. Mail) | Administrator | 9469 OO70 Oc? 6028 &710 42 9489 0090 O02? &024 6710 99 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: A Dream Lake Manor, Inc. d/b/a Apopka Retirement Center AHCA No. 2018006642 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but_must_be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form 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 fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and 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 [ am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 948900900027602867 1082 Your item was delivered at 1:35 pm on July 11, 2018 in APOPKA, FL 32712. Status Delivered July 11, 2018 at 1:35 pm Delivered APOPKA, FL 32712 USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 9489009000276028671099 Your item was delivered to an individual at the address at 2:11 pm on July 7, 2018 in APOPKA, FL 32703. Status Delivered July 7, 2018 at 2:11 pm Delivered, Left with Individual APOPKA, FL 32703

Docket for Case No: 18-005176