STATE OF FLORIDA ges AGENCY FOR HEALTH CARE ADMINISTRATION ~ f STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 06-01-0193-ALF CLIFFORD HILL BOARDING HOME, INC., d/b/a CLIFFORD HILL O /- ily 7 lo BOARDING HOME, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of two thousand five hundred dollars ($2,500) upon Clifford Hill Boarding Home, Inc., d/b/a Clifford Hill Boarding Home (“Respondent”). As grounds for the imposition of this administrative fine, the Agency alleges as follows: (1) The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part III, Florida Statutes. (2) Respondent is licensed by the Agency to operate as an assisted living facility at 1303 BE. New Orleans Avenue, Tampa, Florida 33603, in compliance with Chapter 400 Part III, Florida Statutes, and Rule 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part III, Florida Statutes, and provisions of Chapter 58A- 5, Florida Administrative Code, in that it repeated and/or failed to correct, within the mandated time frame, five (5) deficiencies cited during the previous biennial survey conducted on or about September 28, 1999. The deficiencies, set forth below, were repeated at the subsequent biennial survey conducted on or about August 01, 2001. (a) The Respondent failed to maintain written business records, which accurately reflect the facility’s assets and liabilities and income and expenses. This is a violation of Rule 58A-5.021(2) F.A.C., for which a fine is authorized under Sections 400.414(1) (e) and 400.419(1) (c), Florida Statutes. Class III deficiency. Fine: $500.00. (b) The Respondent failed to have a current fire inspection report on file. This is a violation of Rule 58A-5.015(1) (a) (3), F.A.C. and Section 400.441(1) (a)1,m, Florida Statutes, for which a fine is authorized under Sections 400.414(1) (e) and 400.419(1) {(c), Florida Statutes. Class III deficiency. Fine: $500.00. omen wi ake (c) The Respondent failed to ensure that the administrator of the facility received at least twelve hours of continuing education every two years. This is a violation of Rule 58A-5.0191(1) (c), F.A.C. and Section 400.452(4), Florida Statutes, for which a fine is authorized under Sections 400.414(1) (e) and 400.419(1) (c), Florida Statutes. Class III deficiency. Fine: $500.00. (d) The Respondent failed to ensure that at least one staff member, trained in First Aid and CPR, is within the facility at all times while residents are in the facility. This is a violation of Rule 58A-5.019(4) (a)4, F.A.C., for which a fine is authorized under Sections 400.414(1) fe) and 400.419(1) (c), Florida Statutes. Class III deficiency. Fine: $500.00. (e) The Respondent failed to maintain personnel records verifying that all staff members are free from communicable diseases including tuberculosis. This is a violation of Rule 58A-5.024(2) (a), F.A.C., for which a fine is authorized under Sections 400.414(1) (e) and 400.419(1) (c), Florida Statutes. Class III deficiency. Fine: $500.00. (4) The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.419, Florida Pore Statutes, and Rule 58A-5.033, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an Assisted Living Facility. (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. (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 tec 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. All requests for hearing — ct os shall be made to the Agency for Health Care Administration, Attention: Michael P. Sasso, Senior Attorney, 525 Mirror Lake Drive North, Room 310G, St. Petersburg, Florida 33701. (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 copy hereof has been furnished by U.S. Certified Mail Return Receipt (Z 366 321 313), to Administrator, Clifford Hill Boarding Home, 1303 E. New Orleans Wn Avenue, Tampa, Florida 33603, on this, the 2Y day of November 2001. Fat Red spn PAT REID-CAUFMAN Field Office Manager ' Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: Michael P. Sasso, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 310G St. Petersburg, Florida 33701 ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 5/6 Office Agency for Health Care Administration 525 Mirror Lake Drive North, Room 410A St. Petersburg, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 727 Mahan Drive Tallahassee, Florida 32308 PAYMENT FORM Agency for Health Care Administration Finance & Accounting P.O. Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , Which represents payment of the Administrative Fine imposed by AHCA. Facility Name AHCA No. see me mer reece SE tg gape mer oe CORRE Teer eRe mY pe

Docket for Case No: 01-004876