: STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Ol- We vs. AHCA NO. 03-01-0004-ALF CMRRR: 7000 0600 0026 7844 8446 Petitioner, KIVA OF MOUNT DORA, LLC d/b/a KIVA OF MOUNT DORA, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Kiva of Mount Dora, LLC d/b/a Kiva of Mount Dora (hereinafter “Respondent” ) pursuant to 28-106.201 F.A.C. (2000) and Chapter 120, Florida Statutes, hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of three hundred ($300) dollars pursuant to Section 400.419 (1) (c) Fla. Stat. (2000). Jurisdiction And Venue 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Fla. Stat. (2000) and Chapter 28-106 F.A.C. (2000). : 3. " venue lies in this Court, Division of Administrative Hearings, pursuant to 120.57 Fla. Stat. (2000); and Chapter 28 F.A.C. (2000). Parties 4. AHCA, Agency for Health Care Administration, State of Florida, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 5. Respondent, Kiva of Mount Dora, LLC d/b/a Kiva of Mount Dora, is an assisted living facility located at 505 BE. 9% Street, Mt. Dora, Florida. The facility is licensed under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I KIVA OF MOUNT DORA FAILED TO ENSURE THAT PERSONNEL RECORDS CONTAIN VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE INCLUDING TUBERCULOSIS 58A-5.024(2) (a), F.A.C. (2000) (Tag A1101 —- Staff Records Standards) CLASS IIT 6. AHCA realleges and incorporates (1) through (5) as if fully set forth herein. 7. On or about August 29, 2000 and December 5, 2000, Respondent failed to ensure that personnel records contained verification of freedom from communicable disease including tuberculosis. 8. "on or about August 29, 2000, review of 4 personnel records revealed that four of four (employees A.B., T., S.B. & F.Y.) lacked verification of freedom of communicable disease including tuberculosis (TB). Employee A.B. had a positive TB test in April 1999. A statement in her file stated she may work pending chest x-ray results scheduled May 6, 1999. Despite the surveyor’s request, no chest x-ray results were located by the surveyor or provided by the facility during the entire two day survey. 9. On or about December 5, 2000, review of seven (7) employee files revealed that no employees had a verification of freedom of communicable disease statement in their files. 10. On or about December 5, 2000, an interview with the administrator designee confirmed that seven (7) employees did not have a verification of freedom of communicable disease statement. 11. Based on the foregoing, Respondent violated 58A- 5.024(2) (a), F.A.C. (2000). This class III and the fine amount is $300.00 pursuant to Section 400.419(1)(c) Fla. Stat. (2000). PRAYER FOR RELIEF 12. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: A. Enter a judgment in favor of the Agency for Health Care Administration against Respondent on Count I; B. Assess against Respondent, an administrative fine of $300 for the Class III violation in Count I in accordance with Section 400.419(1)(c) Fla. Stat. (2000). c. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs. D. Grant such other relief as the Court deems is just and proper. 13. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. , ; Field Office Manag Agency for Health Care Administration 5700 S.W. 34™ Street Bureau Building, Suite 1120 Gainesville, Florida 32608 352/955-3070 352/955-3048 (Fax)

Docket for Case No: 01-001166