STATE OF FLORIDA FILED AGENCY FOR HEALTH CARE ADMINISTRATION © ‘'™'"" OO JUN IG PM 12:49 STATE OF FLORIDA DIVISIO AGENCY FOR HEALTH ADHINSTRATIVE CARE ADMINISTRATION : HEARINGS Petitioner, Qe) - ol YG / v. AHCA NO: 06-00-081-NH ‘ HARDEE MANOR CARE CENTER (Diversicare Leasing Corporatibdn, : 0 d/b/a Hardee Manor Care Center), . Respondent. ADMINISTRATIVE COMPLAINT The Agency for Health Care Administration, (hereinafter referred to as the "Agency") files this Administrative Complaint against licensee, Diversicare Leasing Corporation d/b/a Hardee Manor Care Center (hereinafter referred to as "Respondent") who holds license number 1196096. The Agency seeks to REVOKE the Respondent’s nursing home license as the Respondent has failed to meet minimum qualifications specified for a nursing home pursuant to Chapter 400, Part II, Florida Statutes, and alleges as follows: 1. The Agency has jurisdiction over the Respondent ‘pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. VY w) 2. Respondent holds a license to operate a nursing Py home in compliance with Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code, at 401 Orange Place, Wauchula, Florida 33873. 3. Respondent has failed to meet the minimum ‘ qualifications specified for the ownership and operation of a : i a nursing home because the Respondent has not maintained a bond as required by Section 400.179(5) (d), Florida Statutes. The nursing home is leased by the Respondent but the Respondent’s lease bond was cancelled. 4. The conduct of Respondent described above constitutes grounds for the revocation of the Respondent’s license pursuant to Section 400.179(5) (d)5, Florida Statutes. 5. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. Chapter 59-1, Part II, Florida wee Administrative Code, constitutes the Agency's procedural rules for administrative proceedings resulting from this Complaint. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, your request for an administrative hearing must conform to the requirements in Rule 28-106, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to ’ . h dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Division of Managed Care and Health Quality, 6800 North Dale Mabry Highway, Suite 220, Tampa, Florida 33614, Attention: Thomas W. Caufman, Senior Staff Attorney. 6. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST 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. I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt (Number Z 170 444 558) ott 95/03/2008 84:14 __ 8584181512 f . Requested to David Coggin, Administrator, Hardee Manor Care Center, 401 Orange Place, Wauchula, Florida 33873, on the day of May, 2000. MOLLY MCKINSTRY Long Term Care unit * Agency. for Health Care Administration Copies furnished to: Nursing Home Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 PAGE 82/82

Docket for Case No: 00-002461