were STATE OF FLORIDA AGENCY FOR HEALTH, CARE..ADMINISTRATION 7 : STATE OF FLORIDA ” AGENCY FOR HEALTH caRE (02 JAN [} PM 1:5] ADMINISTRATION, . f Petitioner, AD! . AHCA NO: 06-01-0188-NH vs. TAMPA BAY RETIREMENT CENTER INC., d/b/a OAKWOOD PARK SU CASA, Respondent. / L Pp S OAKWOOD PARK SU CASA, Petitioner, vs. CASE NO: 01-3806 . . AHCA NO: 06-01-0228-NH AGENCY FOR HEALTH CARE . RENDITION NO.: AHCA-02-0006-S-OLC ADMINISTRATION, Respondent - . een Risch ee ain 2 aii. atl nek 2 te “The “Agency for’ Hee ing” entered into a Joint Stipulation with the parties to these proceedings, st and being otherwise well advise "decides as with the terms of the Joint Stipulation. lis HB dh The Respondent shall pay the fine within the thirty (30) days after entry of the Final Order. THEREFORE, it is ORDERED and ADJUDGED that the parties hereto are directed to comply with the terms of the Joint Stipulation. DONE and ORDERED this pee day of inl’ | 2001, in Tallahassee, Leon County, Florida. , ; _ Khe M. Age MD, shee Secretary Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA) AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, IN THE DISTRICT COURT OF APPEAL WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF THE RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Eileen O’Hara Garcia, Esquire ~ Agency for Health Care Administration 525 Mirror Lake Drive North Sebring Building, Suite 3107 St. Petersburg, Florida 33701 Nursing Home Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 et see repre ee ae Facility File Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 410A St. Petersburg, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adam: Ce Health Care Administration Florida 32308 Alfred W. Clark, Esquire Attorney for Respondent 117 South Gadsden Street #201 Tallahassee, Florida 32301 Administrator Oakwood Park Su Casa 1514 E. Chelsea Street Tampa, Florida 33610 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to the above-named people by U.S. Mail or Interoffice mail on at , 2008. : G Agency Clerk ae . Agency for Health Care Administration Ft. Knox Building #3 2727 Mahan Drive Tallahassee, FL 32308 (850) 922-5873 ot ad td Sr ERE T= | 5 has BEFORE THE STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA Case Number 06-01-0188-NH ) ) ) - Petitioner, ) ) vs. ) ) TAMPA BAY RETIREMENT CENTER, INC., d/b/a OAKWOOD PARK SU CASA, DOAH Case Number 02-3606 Respondent. AMENDED JOINT STIPULATION The parties, by their undersigned representatives, stipulate and agree as follows: 1. Each party shall bear its own costs. 2. The Secretary of the Agency for Health Care Administration shall enter an order requiring Respondent to pay a fine of $2,250 within 30 days after entry of the Final Order incorporating this Joint Stipulation. 3. Petitioner agrees to accept 75% (seventy-five percent) ($2,250) of the fine assessed in the Administrative Complaint, based upon Respondent's admission of the allegations in the above- referenced Complaint. 4. Respondent, for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Sted pres eps oe gree pears ee tetae 7 ae ie eee ae Sore TOC REET ES RET wk ed Bolsa bees Florida Agency for Health Care Administration and its agents, representatives, and attorneys or and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent cr its related facilities. 5. Respondent shall dismiss its Petition in DOAH Case No. 01-3806. DATED: . ALFR W. CLARK, Esquire 117 South Gadsden St., #201 O°hB/o/ Post Office Box 623 (32302) Tallahassee, Florida 32301 Telephone: 850/224-6161 Florida Bar No. 117914 ee DATED: . As me ie WILLIAM H. ROBERTS , Acting General Counsel LF /¢ AGENCY FOR HEALTH CARE _ ADMINISTRATION 2727 Mahan Drive Tallahassee, FL 32308 Telephone: 850/921-0056 -Page 2- ersyr corer a ee ee ed seme cer iee wh lk (LEB ELIZABETH DUDEK, Deputy Secretary Managed Care and Healty Quality AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Tallahassee, FL 32308 Telephone: 850/921-0056 -Page 3- or arr ORT page rg RET cre CRE EERE TET TR RR RRO TERE” TEPER Re Teer ere saab. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 06-01-0188-NH | TAMPA BAY RETIREMENT CENTER, d/b/a OAKWOOD PARK SU CASA, 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 $3,000.00 upon Oakwood Park Su Casa (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 II, Florida Statutes. ae. (2) Respondent is licensed to operate as a Nursing Home at 1514 E. Chelsea Street, Tampa, Florida 33610, in compliance with * SRR RRR rr RRR ETE ERT eee eR Sa re li ae POOR RET RETR pre LMR A ae wise bl lh Chapter 400, Part II, Florida Statutes, and Chapter S9A-4, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part II, Florida Statutes, and provisions of Chapter 59A~-4, Florida Administrative Code, in that it repeated and/or failed to correct, within the mandated time frame,. one (1) deficiency cited during the survey of June 14, 2001. This deficiency, set forth below, was still uncorrected when a follow-up visit was made on July 24, 2001: (a) The Respondent failed to store, prepare, distribute and serve food under sanitary conditions. This is a violation of Sections 400.23 and 400.141(8), Florida Statutes, and Rule 59A-4.1288, Florida Administrative Code. Class III deficiency. Fine: $3,000.00. 4) The above referenced violation constitutes grounds to levy this civil penalty pursuant to Section 400.23, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regulations for the operation of a nursing home. i * (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. . ended ame ae ea ih Aa tt lel ad ond 2 (6) 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 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 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. Respondent may be entitled to mediation pursuant to Section 120.573, Florida Statutes. Requesting mediation is not a substitute for requesting a hearing. All requests for hearing shall be made to the Agency for Health Care Administration, Division of Managed Care and Health Quality, 525 Mirror Lake Drive North, Ste. 3103, St. Petersburg, Florida 33701; Attention Eileen O’Hara Garcia, 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 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 was sent by U.S. Certified Mail, Return Receipt (2 170 444 496), to Administrator, Oakwood Park Su Casa, 1514 E. Chelsea Street, Tampa, Florida 33610, on the 2% day of ie an 2001. bale Mar Patricia id-Caufman Field Office Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 3107 St. Petersburg, Florida 33701 Nursing Home Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area Office Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 410A St. Petersburg, Florida 33701 Sore terme ae Some eee weer ge er op erg oe ees omer slide al, Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Senge recep caer SORE UTE e ener compe CE RRR Spe RIE re cept pera Rae serene ener oat bea Aas) | STATE OF FLORIDA eS AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY August 9, 2001 , CERTIFIED MAIL ; RETURN RECEIPT REQUESTED Administrator #70993400001384462576 Oakwood Park Su Casa 1514 E. Chelsea St. Tampa, FL 33610 Dear Administrator: NOTICE OF INTENT TO ASSIGN CONDITIONAL LICENSURE STATUS In this case, the imposition of a conditional licensure status is effective July 24, 2001, and is issued Conditional as a result of the survey completed on July 24, 2001. During this survey, an uncorrected Class III deficiency was cited due to failure to follow proper sanitation guidelines in the kitchen. This license reflects your current license status and must be displayed in a conspicuous place in your facility pursuant to section 400.062(5), Florida Statutes, (F.S.). Pursuarit to section 120.569, F.S., you have a right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C.), and must state the material facts you dispute. SEE ATTACHED EXPLANATION OF RIGHTS AND ELECTION OF RIGHTS FORM Sincerely. 2 Molly McKinstry, Program Manager Long Term Care Unit ~ Health Facility Regulation po 2: cc: AHCA Area Office 6 Patricia Hakes, AO 6 Legal Larry Crider, AHCA Specialist File 2727 Mahan Drive « Mail Stop #33 Tallahassee, FL 32308 Visit AHCA online at www dhe. state flus a wr eer so we cel al a a a O19€e Td ‘VdNV.L LARALS VASTSHO “A vIST VSVO NS AAVd GOOMAVO ALTVNO HUTVaH GNV SUV GIOVNVW dO NOISIAIC -NOLLVULSININGY FUVO HLTVaH YOd AONADV BPLIOL] JO 333g TQOOE8ETANS = #.ASNHOIT TIpl # ALVOIMLLYAD eer peg + ene . Spe eee oe pa

Docket for Case No: 01-003806