STATE OF FLORIDA oa AGENCY FOR HEALTH CARE ADMINISTRATION 07 é a a Up, ™ : Yi. p STATE OF FLORIDA 40k, by TW 2, AGENCY FOR HEALTH CARE Haus pi oe °/ ADMINISTRATION Gi WAY , iy Petitioner, vs. AHCA NO: 06-00-024-ALF : PLAZA WEST 01 (Ie) (Michael Johnson, d/b/a Plaza West), Respondent. ADMINISTRATIVE COMPLAINT \ YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from the receipt of this complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency”) intends to impose a civil penalty in the amount of $600.00 upon Plaza West, (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part III, Florida Statutes. (2) Respondent is licensed to operate as an Assisted Living Facility at 912 American Eagle Boulevard, Sun City Center, Florida 33573, in compliance with Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part III, Florida Statutes, and provisions of Chapter 58A-5, Florida Administrative Code, in that it repeated and/or failed to correct, within the mandated time frame, two (2) deficiencies cited during the survey of January 24, 2000. These deficiencies, set forth below, were previously cited at the licensure survey of May 3, 1999: (a) The Respondent failed to maintain accurate, up to-date medication records for residents receiving administration of medications. This is a violation of Sections 400.419(1)(c), and 400.407(3) (b)2, Florida Statutes, and Rule 58A-5.0185(5), and 58A-5.030(9) (a) (2-3), Florida Administrative Code. Class III deficiency. Fine: $300.00. (b) The Respondent failed to ensure that all direct staff members employed in the ECC have the required 2 hours of ECC training within six (6) months after hire. This isa violation of Section 400.419(1) (c), Florida Statutes, and Rule 58A-5.0191(7) (c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (4) The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.414, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an ALF (Assisted Living Facility). (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time, frame for correction. (6) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, 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 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 28-5.201, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to 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 Health Quality Assurance, 6800 North Dale Mabry Highway, Suite 220, Tampa, Florida 33614; attention Thomas W. Caufman, Senior Attorney. Payment of fines shall be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Florida 32317-3749. (Please reference the case number and facility name on the front of your check) . (7) RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEPT 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 259 496 203) Requested, to Michael Johnson, Administrator, Plaza West, 912 American Eagle Boulevard, Sun City Center, Florida 33573, on the 7%, day of WD ceencbe~, 2000. ice Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308

Docket for Case No: 01-001165