LR 3OO STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Certified Article Number ADMINISTRATION, 7106 4S75 Le% COUT 8729 Petitioner, SENDERS RECORD AHCA CASE NO: 2002042601 ~~ ROSALINA C. MATE ral oe z ef d/b/a OVERBROOK MANOR, = 2 og = tS Respondent. = ~ / rt 2 ADMINISTRATIVE COMPLAINT COMES NOW THE AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter referred to as AHCA), by and through its undersigned counsel, and files this Administrative Complaint against Rosalina C. Mate d/b/a Overbrook Manor (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. 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 124 E. Overbrook Dr, Largo, FL. 33770. Respondent 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, having been issued license number 7317. COUNT I RESPONDENT FAILED MAINTAIN COMPLETE AND ACCURATE RECORDS OF FUNDS KEPT FOR SAFEKEEPING. 400.427(3), Fla. Stat. Section 400.19 Fia.Stat. (2001) Class III 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 June 11, 2002, AHCA performed a survey at Respondent's facility. AHCA cited Respondent based on the findings below: to wit: Findings include: During the 3/4/02 survey, the administrator stated that the facility maintained Resident #1's monthly personal allowance. Review of the corresponding account log found a document that could not be readily understood in that it consisted of random figures being added with no semblance of order. Thus, this and other residents whose personal monies were being handled by the facility were at risk of not having an accurate accounting of their funds. 9. Based on all of the foregoing, Respondent has violated Section 400.427(3), Fla. Admin. Code, by failing to maintain complete accurate records of those funds kept for safekeeping. 10. The foregoing violation constitutes a Class III violation. Class "HI" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class IT violations. A Class III violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. 11. This violation constitutes a repeat and/or uncorrected violation from a survey dated on or April 3, 2002. Respondent was provided a mandated correction date of June 7, 2002. 12. Said violation constitutes an uncorrected Class III and warrants imposition of the fine of $1000. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: a) Enter factual and legal findings in favor of AHCA. b) Impose a fine in the amount of $1000.00; and c) Any other general and equitable relief as deemed appropriate. COUNT II RESPONDENT FAILED CONTAIN ANY VERBIAGE PERTAINING TO FACT THE RESIDENT/REPRESENTATIVE SHALL BE ALLOWED TO RECEIVE A REFUND IN THE RESIDENTS CONTRACT. 400.424(3)(a) Fla. Stat. Section 400.19 Fla.Stat. (2001) Class III deficiency 13. AHCA re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 14. On or about June 11, 2002, AHCA performed a survey at Respondent's facility. AHCA cited Respondent based on the findings below: to wit: Findings include: Review of the resident contract during the survey found a document that did not contain any clause/provision that indicated that once the contract was terminated, the resident/representative would be allowed a period of no less than 14 calendar days to respond to any claim against the refund. 15. Based on all of the foregoing, Respondent has violated Section 400.427(3), Fla. Admin. Code, by failing to maintain complete accurate records of those funds kept for safekeeping. a ~w 16. The foregoing violation constitutes a Class II violation. Class "III" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A Class III violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. 17. This violation constitutes a repeat and/or uncorrected violation from a survey dated on or April 3, 2002. Respondent was provided a mandated correction date of June 7, 2002. 18. Said violation constitutes an uncorrected Class IfI and warrants imposition of the fine of $1000. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: d) Enter factual and legal findings in favor of AHCA. e) Impose a fine in the amount of $1000.00; and f) Any other general and equitable relief as deemed appropriate. Dated fade | (og Agency for Health C Administration Senior Attorney-Fla. Bar. No. 0240389 2727 Mahan Drive Building 3, Mail Stop #3 Tallahassee, Florida 32308 (850) 922-5865 (office) (850) 921-0158 (fax) NOTICE Respondent, ROSALINA C. MATE d/b/a OVERBROOK MANOR hereby is notified that Respondent 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 Heaiin Care Adviinistration, 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 Qt {WL AGENCY FOR HEALTH CARE ADMINISTRATION (? / mf) (06 — ; Rictrard Boseph 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) 922-5865 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE IT 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 # 7106457512948792)Rosalina C. Mate d/b/a Overbrook Manor, 124 E Overbrook Drive, Largo, Florida 33770 this 15¢ day of July, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION es pet abla arWJoseph 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) 922-5865 (office) (850) 921-0158 (fax)

Docket for Case No: 02-003360