“ ~ - BPO STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Certified Article Number ADMINISTRATION, Piob 4575 le4 2049 2722 SENDERS RECORD Petitioner, AHCA CASE NO:2002016671 “” 2, CHANCELLOR OF CLEARWATER, INC. D/B/ACHANCELLOR GARDENS AT COUNTRYSIDE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW AHCA FOR HEALTH CARE ADMINISTRATION (hereinafter referred to as AHCA), by and through its undersigned counsel, and files this Administrative Complaint against CHANCELLOR OF CLEARWATER, INC, D/B/A CHANCELLOR GARDENS AT COUNTRYSIDE, (hereinafter referred to as “Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2001), and alleges the following: Nature of the Action 1. This is an action to impose an administrative fine upon Respondent pursuant to Sections 400.419(1) (b), Florida Statutes Jurisdiction And Venue 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. ww — 3. AHCA has jurisdiction over Respondent pursuant to Chapter 400 Part III, Florida Statutes. 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code. Parties 5. Pursuant to Chapter 400, Part III, Florida Statutes, and Rules 58A-5, Florida Administrative Code, AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. Respondent is an assisted living facility located at 3141 N. McMullen Booth Road, Clearwater, Florida. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter S8A-5, Florida Administrative Code, having been issued license number 9748. COUNT I Respondent effected an increase in rate without the requisite 30 days written notice. Rule 58A-5.025(1) (d) Fla. Admin. Code Section 400.19 Fla.Stat. (2001) CLASS IV DEFICIENCY 7. AHCA re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 8. On or about February 13, 2002, AHCA performed a survey at Respondent’s facility. AHCA cited Respondent based on the findings below:, to wit: The resident contract contained a provision for at least 30 days prior written notice of rate increase. The facility failed to comply with this contract provision. Based upon a review of one resident record and review of the residents contract, at least 30 days written advanced notice was not provided of rate increase. The record contained a letter dated 7/23/01 notifying the resident/responsible party that effected 8/1/01 a 4% rate increase of the basic rate would take place. This notification was only 8 days prior to the date of the rate increase. 9, Based on all of the foregoing, Respondent has violated Rule 58A-5.025(1) (d) Florida Administrative Code, by failing to comply with the thirty day notice prior to a rate increase. 10. The foregoing violation constitutes a Class IV violation. Class "IV" violations are those conditions or occurrences related to the operation and maintenance of a building or to required reports, forms, or documents that do not have the potential of negatively affecting residents. These violations are of a type that the agency determines do not threaten the health, safety, or security of residents of the facility. 11. Respondent was provided a mandated correction date of February 9, 2002, in accordance with Section 400.419(1) (da), Florida Statutes. 12. Said violation constitutes an uncorrected Class IV and warrants imposition of the fine of $200 fee. 13. Section 400.419(9) authorizes assessment of a survey In the context of the present facts and circumstances a survey fee is assessable as this administrative complaint is predicated upon an original complaint survey citing a tag related to the confirmed complaint Dated CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: a) Make factual and legal findings in favor of AHCA. b) Impose a fine in the amount of $200; and c) Impose and assess survey fee of $500.00 in addition to the assessed fine. d) Any other general and equitable relief as deemed appropriate. HH, or Agency for Health vi Administration Riehard @ al! Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) NOTICE Respondent, CHANCELLOR OF CLEARWATER, INC, D/B/A CHANCELLOR GARDENS AT COUNTRYSIDE hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for a hearing shall be sent to AHCA, Richard Joseph Saliba, Esquire, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY AHCA. Dated ma (I, Yet AGENCY FOR 77s ADMINISTRATION Rr@han oseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint has been sent by U.S. Certified Mail, Return Receipt Requested, (Return Receipt #7106 4575 1294 2049 7722).to CHANCELLOR OF CLEARWATER, INC, D/B/A CHANCELLOR GARDENS AT COUNTRYSIDE, 3141 N. McMullen Booth Road, Clearwater, Florida 34695 this tr day of June, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION Pon prt tele Rithard #oseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) STATE OF FLORIDA AGENCY FOR HEALTH CARE “ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used in conjunction with Election of Rights form — attached) In response to the allegations set forth in the Administrative Complaint issued by AHCA for Health Care Administration (“AHCA” or “Agency”), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2, If you do not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes (2001) before AHCA. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes (2001). To obtain a formal hearing, select OPTION 3 on the Election of Rights form. 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. IN ORDER TO PRESERVE YOUR RIGHT TO A HEARING, YOUR ELECTION OF RIGHTS IN THIS MATTER MUST BE DIRECTED TO AHCA BY FILING WITHIN TWENTY-ONE (21) DAYS FROM THE DATE YOU RECEIVE THE ADMINISTRATIVE COMPLAINT. IF YOU DO NOT RESPOND AT ALL WITHIN TWENTY-ONE (21) DAYS FROM RECEIPT OF THR ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ISSUED FINDING YOU GUILTY OF THE VIOLATIONS CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT. & % > STATE OF FLORIDA inte AGENCY FOR HEALTH CARE ADMINISTRATION. Y fo AOS i, RE: CASE NAME cHaNcELOR GARDENS AT CLEARWATER. INC. dib/a CHANCELOR Galwefis:ar COUNTRYSIDE CASE NO. 2002016671 Gen ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 6 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 6 ! do not dispute and ! admit the allegations of fact in the Administrative Complaint, wut du wisit io be afforded an informal Proceeding, purouai io Seciiurs (20,07(2), Fiutides Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) 6 Ido dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), 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. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. if you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. If you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 0 Mediation under Section 120.573, Florida Statutes, is not available in this matter, SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF AFINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: License. No. and facility type: : Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Richard Saliba,Esquire, GENERAL COUNSEL OFFICE, Agency for Health Care Administration, 2727 Mahan Drive MS#3, Tallahassee, FL. 32308. Telephone Number: 850-922-5873; FAX 850-413-9313; TDD 1-800-955-8771.

Docket for Case No: 02-002901