STATE OF FLORIDA oo AGENCY FOR HEALTH CARE ameanzstrazoy, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 45 yg 4 Petitioner, AHCA NO: 2020%8041 vs. O04 G OAKLAND MANOR, 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 OAKLAND MANOR, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of One Thousand Dollars ($1000) Pursuant to Sections 400.414(1) (a) and 400.419(1) (c) Florida Statutes. 2. The Respondent was cited for the uncorrected Class III deficiency set forth below as a result of a follow-up survey conducted on or about April 17, 2002 from a prior survey of February 25, 2002. The original mandated correction date was February 26, 2002. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part III, Florida Statutes. 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. PARTIES 5. AHCA, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 2812 North Nebraska Avenue, Tampa, Florida 33602. The facility is licensed under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO NOTE BEFORE OR WHEN THE MEAL IS SERVED, SUBSTITUION OF REGULAR AND THERAPEUTIC MENUS. VIOLATING FL. ADMIN. CODE 58A-5.020(2) (d) UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On the date of this follow-up visit, at approximately 9:30am it was determined that the posted breakfast menu did not reflect the actual breakfast served on that date. The staff indicated that the menu was not followed as the food items needed to prepare the menu were not available in the food inventory. The menus posted had not been corrected as served for the breakfast meal on 4/17/02. This was a repeat deficiency from the survey of February 25, 2002. 9. The above actions or inactions violate Fl. Admin Code R. 58A-5.020(2) (d) which requires, in pertinent part, that regular and therapeutic menus as served, with substitutions noted before or when the meal is served shall be keep on file in the facility for six months. 10. The above referenced violation constitutes the grounds for the one (1) uncorrected Class III deficiency and for which a fine of One Thousand Dollars ($1000) is impose pursuant to §$400.419(1) (ec) Florida Statutes. 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. Impose a total fine of One Thousand Dollars ($1000) for the violation cited in Count I, against the respondent under Section 400.414(1) (e) and 400.419(1) (c), Florida Statutes. Cc. Assess costs related to the investigation and prosecution of this case pursuant to $400.121(2) Florida Statutes, and D. All other general and equitable relief allowed by law. NOTICE OAKLAND MANOR is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) 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 AGENCY. (| Lion Oy res Eileen O’Hara Garcia, Esquire AHCA ~ Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to Lisa McCarthy, Administrator/Owner, 13807 Shady Shores Drive, Tampa, Florida 33612, Return Receipt No. 7099 3400 0002 2450 7750, by U.S. Certified Mail, and Roger D. Reynolds, Corporate Officer for Oakland Manor, 9063 East River Road, Venice, Florida 34293, U.S. Mai November | of, 002. [ Us (Y bina ee Eileen O’Hara Garcia, Esquire Copies furnished to: Lisa McCarthy Administrator/Owner of Oakland Manor 13807 Shady Shores Drive Tampa, Florida 33612 (U.S. Certified Mail) Roger David Reynolds Corporate Officer for Oakland Manor 9063 East River Road Venice, Florida 34293 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Alberta Granger Assisted Living Facilities Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS Code #30 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701

Docket for Case No: 03-000190