FILED Te JUN-1 01 . STATE OF FLORIDA AHCA . + AGENCY FOR HEALTH CARE ADMINISTRATION DEPARTMENT CLERK oO wt, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA CASE NO.: 04-01-0014-AE, vs. O\ ~ LDC. BEATRIZ PAR & MARINA CAMPOS d/b/a DELLWOOD RETIREMENT HOME, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY notified that after twenty-one (21) days from 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 $5,000.00 upon BEATRIZ PAR & MARINA CAMPOS d/b/a DELLWOOD RETIREMENT HOME (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 by virtue of the provisions to Chapter 400 Part III, Florida Statutes (2000) and Section 58A-5, Florida Administrative Code. (2) Respondent is licensed to operate as an Assisted Living Facility at 2264 Dellwood Retirement Home, Jacksonville, Florida 32204, in compliance with Chapter 400 Part III, Florida Statutes (2000), and Rule 58A-5, Florida Administrative Code. (3) The Respondent has violated the previsions of Chapter 400 Part III, Florida Statutes (2000) and provisions of Chapter 58A-5, Florida Administrative Code, in that it was cited for one (1) deficiency during an ALF appraisal visit conducted on April 26, 2001. (a) (A1000) The Respondent was not in compliance with building construction codes and the documented evidence of violations put residents in immediate danger of death or serious physical harm. This is a violation of Section 400.419(1)(a), and Section 400.444(1), Florida Statutes (2000). Class I deficiency. Fine: $5,000.00. (4) Notice was provided in writing to the Respondent of each of the above violations and the time frame for correction. The agency is authorized to impose this fine pursuant to Chapter 400.419(1)(a), and Section 400.444(1), Florida Statutes (2000), and Rule 58A-5, Administrative Code. (5) Respondent is notified that they have a right to request an administrative hearing pursuant to 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 they request a hearing. The election and explanations of rights are attached and incorporated by reference and will substitute pursuant to 120.57 Florida Statutes, 120.57, Florida Statutes. All requests for hearing and payment of fines shall be made to the Agency for Health Care Administration, Building 3, Suite 3431, 2727 Mahan Drive, Tallahassee, Florida 32308; Attention: Michael O. Mathis, 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 thé case fiumber and facility name on the front of your check)... (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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereby was sent by U.S. Certified Mail, Return Receipt Requested, to Beatriz Par, Administrator, Dellwood Retirement Home, 2264 Dellwood Avenue, Jacksonville, Florida 32204 on this UPaay of é BAf_,2001. Copies furnished to: Michael O. Mathis, Esquire Senior Attorney Agency for Health Care Administration Mail Stop #3 2727 Mahan Drive Building 3, Suite 3408D Tallahassee, FL 32308 Finance & Accounting Agency for Health Care Administration Bldg. 2, 2" Floor 2727 Mahan Drive’ Tallahassee, Florida 32308 \ Karen Swann ; . Area #4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 North Davis Street, Suite 115 Jacksonville, FL 32209 Beatriz Par, Administrator Dellwood Retirement Home. 2264 Dellwood Avenue Jacksonville, Florida 32204 Karen Swann Area #4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 North Davis Street, Suite 115 Jacksonville, FL. 32209

Docket for Case No: 01-002502