STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ()\-160"1 STATE OF FLORIDA AGENCY FOR HEALTH CARE ’ ADMINISTRATION, Petitioner, AHCA NO. 03-01-0016-ALF vs- | Certified Article Number THE MANOR OF CROSS CITY, INC. 7hOb 4575 1294 2049 7470 d/b/a THE MANOR OF CROSS CITY, Gz: ERS RECORD INC. N.P., Respondent. ADNTNTSTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against the Manor of cross City, Inc. d/b/a The Manor. of Cross City,. Inc. N.P. (hereinafter “Respondent”) pursuant to 23-106.201 F.A.C. and Chapter 120, Florida Statutes (2000) and hereinafter alleges: TURE OF “THE ACTION “~~ 1. This is an action to impose an administrative fine in “the amount of one thousand ($1,000) dollars pursuant to Section 400.419 Fla. Stat. (2000). Jurisdiction And Venus 2. This Court has jurisdiction purstant 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, The Manor of Cross City, is an assisted living facility located at 401° Stockade Road, Cross City, Florida. The facility is licensed under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code (2000). _couNT =I _RESPONDENT FAILED * TO. ENSURE ‘THAT "THE FACILITY HAD "AN UP-TO-DATE FIRE INSPECTION 58A-5. 024(1)(m),_ F.A.C. (2000) (Tag A210 - Facility Records Standards) CLASS ir 6. AHCA, realleges and incorporates (1) through (5) as if fully set forth herein. “by the State Fire Inspector 7. On or about September 7, 2000 and October 19, 2000, Respondent failed to ensure that the facility had an up-to-date fire inspection. 8. On or about September 7, 2000 during an exit. conference with representatives from the State Fire Marshal’s Office, the facility was informed that it was not in compliance with their fire ‘safety inspection as of this date. 9. On or about September 7, 2000 during the facility tour, it was discovered that the facility had not installed a hood | suppression system or updated the alarm system as required 10. The Respondent was given written notification of the cited deficiency and the time frame for correction. 11. “Based on “the foregoing, "Respondent violated 58a- 5.024(1) (m), F.A.C. (2000) . This is a class Ir violation and the Agency is authorized to impose the fine amount of $1,000.00 pursuant to Secti 400.419 (1)(b) Fla. Stat. (2000). | PRAYER FOR RELIEF ABs 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; otek B. Assess against Respondent én administrative fine of $1,000 for Count I in accordance with Section 400.419 Fla, Stat. (2000). Cc. Grant such other relief as the Court deems is just and proper. 13. The Manor of Cross City has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, and 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 adnission of the facts _ — alleged in the complaint and the entry of a final order by the Agency. CORA KURTZ Field Office Manager, Area 3 Agency for Health Care Administration 5700 S.W. 34 Street «. Bureau Building, Suite 1120 Gainesville, Florida 32608 aa 352/955-3070 (Fax) meme oe - Certificate of Service I HEREBY CERTIFY that a true and correct copy of the foregoing complaint and election of “rights was sent by U.S. Certified Mail, Return Receipt Requested to Administrator, The Manor of Cross City, 401 Stockade Road, Cross City, FL 32628, on this of day of Febcuney 2001. aN A racing TRACEY S. COT CLE Copies furnished: Gloria Collins Agency for Health Care Administration Finance and Accounting Cora Kurtz Area Office 3 5 5 f ' :

Docket for Case No: 01-001609