4p ole, STATE OF FLORIDA nT aS AGENCY FOR HEALTH CARE ADMINISTRATION Ree q: STATE OF FLORIDA, AGENCY FOR CE ay HEALTH CARE ADMINISTRATION, TEER OLE Petitioner, AHCA NO: 200107655 vs. ACMC-OCALA, INC., d/b/a PARK PLACE RETIREMENT d/b/a PARK PLACE OF OCALA, Respondent. 81:6 WY GI Yd¥ 20 ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against ACMC-OCALA, INC., d/b/a PARK PLACE RETIREMENT d/b/a PARK PLACE OF OCALA, (“Park Place of Ocala”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2001), alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Park Place of Ocala, pursuant to Section 400.419(1)(b), and 400.428(1)(a), Fla. Stat. (2001). JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, (2001). 3. Venue lies in Marion, Ocala, Florida, pursuant to Section 120.57, Florida Statutes, (2001); and 58A-5, Florida Administrative Code (2001), 28.106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes, (2001), and Chapter 584-5, Florida Administrative Code. 5. Park Place of Ocala is a for-profit corporation, whose 110-bed assisted living facility is located at 9070 SW 80" Avenue, Ocala, Florida. Park Place of Ocala is licensed as an assisted living facility license #AL9441; certificate number 9610, effective January 21, 2001 through January 20, 2002. Park Place of Ocala was at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT 1 PARK PLACE OF OCALA FAILED TO PROVIDE A SAFE ENVIRONMENT ALLOWING ONE RESIDENT TO FALL AND BE INJURED. STATE TAG-A999- RESIDENTS RIGHTS 400.428(1)(a), Florida Statutes (2001) 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On the original survey of June 27, 2001, Park Place of Ocala failed to provide a safe environment allowing one resident to fall and be injured. The above constitutes a violation of Section 400.428(1)(a), and Section 400.414(1)(a), Florida Statutes (2001), requiring the facility to ensure that all resident live in a safe and decent living environment, free from abuse and neglect. This is a class II deficiency. Fine: $1,000.00. The above constitute a violation of 400.419(1)(b), Florida Statutes (2001), provides that class II violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of facility residents, other than class I violations. A class II violation is subject to an administrative fine in an amount not less than $1,000 and not exceeding $5,000 for each violation. A citation for a class IL violation must specify the time within which the violation is requested to be corrected. This above constitutes a violation of Section 400.419(9), Florida Statutes (2001), requires that in addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the conducting initial complaint or monitoring visits conducted under s. 400. 28(3)(c) to verify the correction of the violations. Fee: $232.50. WHEREFORE, AHCA intends to impose an administrative fine against Park Place of Ocala for violation of Section 400.419(1)(b), and 400.428(1)(a), Fla. Stat. (2001). Park Place of Ocala is an assisted living facility in the State of Florida. 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED 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, st Respectfully Submitted this (= day ot arch 2002. Michael ©. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0055 (office) (850) 413-9313 (fax) Cora S. Kurtz Diane Grubbs Agency for Health Care Administration CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on LF ay, of Lact 2002 to Debby Duncan, Administrator, Park Place of Ocala , 9070 SW 80" Avenue, Ocala, Florida 34481.

Docket for Case No: 02-001597