PAGE 82 87/22/2882 14:28 7275521440 AHCA y , YPN oo 4-3 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Patitioner, vs. AHCA NO.8~-01-0023 ALF SARDONYX ASSOCIATES LIMITED PARTNERSHIP d/b/a PERIDOT PLACE/THE WOODLANDS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA"), by and through the undersigned counsel, files this Administrative Complaint against Sardonyx Associates Limited Partnership d/b/a/ Peridot Place/The Woodlands (hereinafter)” Peridot”) pursuant to 28-106.201 Florida Administrative Code (2000) (F.A.C.) and Chapter 120, Florida Statutes ("F.S.") and hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Nineteen Thousand Two Hundred Twenty Eight dollars with Ninety-Five Cents ($19,228.95) dollars pursuant to Section 400.424(3) (a) F.S. a: 7/22/2802 14:28 7275521448 AHCA PAGE 63 JURISDICTION AND VENUE EN AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57 P.g. and Chapter 28-106 FLA.C. 3. Venue lies in this Court, Department of Administrative Hearings, pursuant to 120.57 F.S and Chapter 28 F.A.C. PARTIES 4. AHCA, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part ITI, F.S. and Rules 58A-S, F.A.c. 5. Peridot is an assisted living facility located at 825 Santa Barbara Boulevard, Cape Coral, Florida, 33991, and is licensed under Chapter 400, Part III, F.S. and Chapter 58A-5s, F.A.LC, 6. Peridot has violated the provisions of Chapter 400, Part III, F.S. and the provisions of Chapter S58A-5, F.A.C., in that it failed to make a refund of resident funds, ag required, within 45 days. 7. Based upon record review and interview it was determined the facility failed to refund resident security deposits within 45 days after transfer, discharge, or death of the resident for 3 of 4 sampled closed resident records (Resident #2, #3 and #4). 8. A review of the facility's Admission and Financial Agreement revealed that the facility requires under the 87/22/2902 14:28 7275521448 AHCA PAGE ad Financial Agreement Section (la) a security deposit equal to one month's monthly room rate collected upon admission. Security deposit will be kept in an account separate (Sun Trust/Southweet Florida) from the funda and property of facility and other residents, 9. Section 3 of thig same Section indicates in part, "If the facility doea not need to withhold unused advance payment, then reimbursement will be paid within 45 days or receipt of the written notice of termination or after unit ia vacated (except in discharge due to medical/mental health reasons) . Facility shall provide an itemized list of deductions. The party shall have fourteen (14) days to response. If there is no response, deductions will be accepted as stated." 10. Resident #2 was admitted on 7/18/99 and placed with the facility a security deposit in the amount of $1,495.00. The Resident expired on 9/30/00. A refund, less $35.00 for carpet cleaning, should have been issued by the facility no later than 11/14/00. Ina telephone interview with a financial representative from the corporate office on 3/30/01 at 1:00 P.M., the surveyor was informed that a credit memo had been issued on 11/13/00. However, the facility had not issued a check to the Resident's legal representative as of 3/30/01. ll. Resident #3 was admitted on 4/10/99 and placed with the facility a security deposit in the amount of $1,448.00. The 87/22/2882 14:28 7275521448 AHCA PAGE Resident expired on 10/2/00. aA refund, less $35.00 for Carpet cleaning, should have been issued by the facility no later than 11/16/00. Ina telephone interview with a financial representative from the corporate office on 3/30/01 at 1:00 P.M., the surveyor was informed that a credit memo had been issued on 2/5/01. However, the facility had not igsued a check to the Resident's legal representative as of 3/30/01. 12. Resident #4 was admitted on 12/15/98 and placed with the facility a security deposit in the amount of $2,140.00. The Resident expired on 10/9/00. A refund, less $35.00 for carpet cleaning, should have been issued by the facility no later than 11/23/00. In a telephone interview with a financial representative from the corporate office on 3/30/01 at 1:00 P.M., the surveyor was informed that a credit memo had been issued on 11/22/00. In addition to the security deposit refund the Resident is entitled to a prorated refund of their monthly service charge in the amount of $1,431.65. However, the facility had not issued a check to the Resident's legal representative as of 3/30/01. 13. Based on the foregoing, Peridot violated 400.424(3) (a), F.S. herein classified as a class IIT violation, which carries, in this case, an assessed fine of $19,228.95. 85 87/22/2882 14:28 7275521448 AHSA PAGE 46 PRAYER FOR RELIEF 14. WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: A. Enter a judgment in favor of the Agency for Health Care Administration against Peridot based on the violations described above. B. Assess against Peridot an administrative fine of $19,228.95 for the violations noted in paragraph 13 above, in accordance with Section 400.424 (3) (a) F.g. c. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs. D. Grant such other relief as the court deems is just and proper. 15. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT To THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Issued this ae. day of Bag et , 2001. OC B7/22/2882 14:28 7275521448 ANCA PAGE 87 Harold D. Williams Pield Office Manager Agency for Health Care Administration 2295 Victoria Avenue Room 340 Ft. Myers, Florida 33901 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing complaint and election of rights was sent by U.8. Certified Mail, Return Receipt Requested to Administrator, Richard James Hileman, Peridot Place/The Woodlands, 825, Santa Barbara Boulevard, Cape Coral, Florida 33991, and Peter J. Gravina, 1933 Hendry Street, Fort Myers, Florida 33901, on thie of. Z day of » 2001, Copies furnished: Pury Lopez Santiago Assistant General Counsel Agency for Health Care Administration 8355 NW 53°? street Miami, Florida 33166 fa enema O7/22/2802 14:28 7275521448 AHCA PAGE 88 Harold D. Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue Roam 340 Ft. Myers, Florida 33901 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 ALF Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308

Docket for Case No: 02-003488