STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. SOUTHERN GARDENS, 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 Southern Gardens (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Southern Gardens in the amount of one thousand dollars ($1,000) pursuant to Sections 400.414 (1) (a) and 400.419(1) (b) Florida Statutes. - . Sarisdiction and Venue 2. This Court has jurisdiction pursuant to section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. Seer EPO We erree-reerreeeeee meeeeen' t * 3. Venue lies in Polk County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. 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, Southern Gardens, is an assisted living facility located at 255 East Main St., Lake Alfred, Florida. Southern Gardens, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO COMPLY WITH THE RESIDENT’S BILL OF RIGHTS, VIOLATING 400.428(1) Fla. Stat. CLASS II DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about July 06, 2001 a survey was conducted respondent’s facility with the below deficiency being cited. The deficiency was previously cited during a survey conducted on or about June 12, 2001. 8. Based upon observations made by the surveyor, and interviews conducted at the facility, during the July 06, 2001 survey, it was determined that the facility continued in its failure to comply with the Resident’s Bill of Rights. This deficiency was based upon the facilities action of denying Resident #3 access to her motorized wheelchair. 9. The above referenced action is a violation of Section 400.428(1) Florida Statutes; setting forth the rights afforded to residents of assisted living facilities. 10. The above referenced violations constitute the grounds for the imposed Class II deficiency and for which a fine of one thousand dollars ($1,000) is authorized under Sections 400.414(1) (a) and 400.419(1) (b) Florida Statutes. WHEREFORE, AHCA intends to impose a fine against the Respondent under Section s 400.414(1) (a) and 400.419(1) (b) Florida Statutes in the amount of one thousand dollars ($1,000). The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Michael P. Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. Respectfully submitted, f Michael P. Sasso, Esquire AHCA -— Senior Attorney 525 Mirror Lake Drive North Sebring Building, Suite 310G St. Petersburg, Florida 33701 (727) 552-1435 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail Return Receipt (Z 170 444 510) Requested, to Karen Lazarz, Interim Administrator of Southern Gardens, 255 E. Main Street, Lake Alfred, Florida 33850, on the (err day of Oebfer , 2001. Wuckal f_feoo— Michael P. Sasso, Esquire Copies furnished to: ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 7 Office Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, $309 Orlando, Florida 33701 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

Docket for Case No: 01-004647