STATE OF FLORIDA “ AGENCY FOR HEALTH CARE ADMINISTRATION’ STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, 02 -YUeTy AHCA NO: 2002038811 vs. SECOND FLORIDA LIVING OPTIONS, LLC, d/b/a HAWTHORNE CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against SECOND FLORIDA LIVING OPTIONS, LLC, d/b/a HAWTHORNE CARE CENTER (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose a fine of $1000 pursuant to §400.23(8) (c) Florida Statutes. 2. The Respondent was originally cited for the deficiency during the follow up survey of March 25, 2002. The deficiency remained uncorrected at the visit of May 20, 2002 JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 851 West Lumsden Road, Brandon, FL 33511. ‘The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I FACILITY FAILED TO HAVE AN AUTOMATIC SPRINKLER SYSTEM WITH AN ELECTRICALLY SUPERVISED MAIN CONTROL VALVE SO AT LEAST A LOCAL ALARM WILL SOUND WHEN THE VALVES ARE CLOSED Fl. Admin Code R. 4.130 UNCORRECTED CLASS THREE DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about May 20, 2002 a Life Safety Code revisit was conducted at the facility. At that time it was determined that the outside stem and yoke control valves did not have electronic supervisory “tamper” switches to assure that a local alarm is received at a constantly attended location when the valves are closed. This deficiency was originally cited at the prior follow up survey of March 25, 2002 and remained uncorrected to the revisit survey of May 20,2002. 9. The above actions or inactions are a violation of Fl. Admin Code R. 59A-4.130 which requires that licensees shall comply with life safety code requirements at time of approval of the facility’s Third Stage - Construction Documents. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Recommend that the fine of $1000 be upheld; and c. Assess costs related to the investigation and prosecution of this case pursuant to §400.121(10) Florida Statutes. D All other general and equitable relief allowed by law. NOTICE SECOND FLORIDA LIVING OPTIONS, LLC, d/b/a HAWTHORNE CARE CENTER is notified that it has a right to request an administrative hearing pursuant to §120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (two pages) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, St. Petersburg, Florida 33701. RESPONDENT IS FURTHER NOTIFIED 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 Eileen O’Hara Garcia) Esquire AHCA - Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drivé, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1625 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to Corporation Service Company, 1201 Hays Street, Tallahassee, FL 32301 by U.S. Certified Mail, Return Receipt No.7002 0510 0003 Care Center, 851 Lumsden Road, B on October | th 2002. Copies furnished to: Corporation Service Company Registered Agent for Hawthorne Care Center 1201 Hays Street Tallahassee, FL 32301 (U.S. Certified Mail) Deborah K. Franklin, Administrator Hawthorne Care Center 851 West Lumsden Road Brandon, Florida 33511 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701

Docket for Case No: 02-004676