@ e. Ml STATE OF FLORIDA ppp ee AGENCY FOR HEALTH CARE ADMINISTRA one ; . a tn P “4/ iy ? 1% STATE OF FLORIDA AGENCY FOR HEALTH CARE ies ADMINISTRATION, 70 3901, emauh | 0785 0523 SENDERS RECORD Petitioner, ieee v. AGENCY NO: 2003000590 Lake Placid Retirement Villas, Inc. Certified Mail No. dba Rosewood Senior Care Villas 7160 3901 9844 0785 0523 - _ < xO Respondent. 0 i) 5 2 / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTHCARE ADMINISTRATION (“AGENCY”), by and through the undersi gned counsel, and files this Administrative Complaint against Rosewood Senior Care Villas (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57 Florida Statutes (2002), and alleges: Nature of the Action 1. This is an action for licensure suspension and/or licensure revocation pursuant to Sections 400.414(1)(n) and 400.4275(3) Florida Statutes. Jurisdiction And Venue 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. Vdanele ge sssane pant te 3. Venue lies in Highlands County. Division of Adminictrati+ Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. Parties A. AGENCY, 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. 5. Respondent, is an assisted living facility located at 517 U.S. 27 North, Lake Placid, Florida 33852. 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. COUNT I RESPONDENT FAILED TO MAINTAIN LIABILITY INSURANCE COVERAGE Fla. Admin. Code R. 58A-5,021(8); Sections 400.4275(3), And 400.414(1)(n) Fla. Stat. (2002) 6. The AGENCY re-alleges and incorporates paragraphs (1) through (5) above as if. fully set forth herein. 7. On or about January 10, 2003, the AGENCY verified that the Respondent’s liability insurance policy had expired. 8. On or about January 10, 2003, the AGENCY sent a Notice of Violation to the Respondent requesting the Respondent to submit evidence that liability insurance coverage was obtained, 9. Respondent failed to maintain liability coverage at all times in accordance with licensure requirements of Rule 58A-5.021(8) Fla. Admin. Code; and section 400.4275 (3) Fla. Stat. 5 du. FUE te dion HabUNy WISUTANCe COV uee aoa Hite CUusulules an act upon which a license may be suspended or revoked pursuant to section 400.414(1)(n), Fla. Stat. (2002). CLAIM FOR RELIEF WHEREFORE, the AGENCY respectfully requests the following relief: 1) Factual and legal findings in favor of the AGENCY on Count I; 2) Upholding the AGENCY’S imposition of license suspension and/or revocation. Respondent is notified that it has a right to request an administrative hearing pursuant to section , , 120.569 and 120.57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Ri ghts (one page). All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop Code #3, Tallahassee, Florida, 32308; Ursula Eikman, Attorney. "4 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A ‘4 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. vy Respectfully Submitted, A / Ursula Eikman Agency for Health Care Administration FBN USu0y4i 2727 Mahan Drive, MS-3 Tallahassee, FL 32308 (850) 413-0899 I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail Return Receipt No. 7160 3901 9844 0785 0523, to Respondent, this av 7B of March ee? Ursula Eikman Py sag STATE OF FLORIDA ‘ if & AGENCY FOR HEALTH CARE ADMINISTRATION Pep EXPLANATION OF RIGHTS UNDER SEC. 120.569, none geariTl b 7, HOT ‘4 (To be used with Election of Rights for Administrative Complaint foe ane in response to the allegations set forth in the Administrative Complaint tested by the Agency for Health Care Administration (“AHCA” or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Compiaint and your Election of Rights in this matter must be received by AHCA within twenty- one (21) days from the date you receive the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed , on the form. OPTION 1. !f Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent 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 Complaint. You will be provided a copy of the final order. OPTION 2. ‘If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Compiaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent 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, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. If the Respondent disputes 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. To obtain a formal hearing, Respondent should 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., Respondent’s 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 disputed. IF YOU SELECT OPTION 3, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the rinht to a hearing. Resnondent’s Flection of Riahts in this matter ek THE UiiGelin receives the “Administrative Complaint. If the election of rights iorm with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of Respondent's receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. @ ] Lee, ran STATE OF FLORIDA gp “4, AGENCY FOR HEALTH CARE ADMINI TION y RE: LAKE PLACID RETIREMENT VILLAS, INC. d/b/a ROSEWOOD SENIOR CARE VILLAS ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. ; OPTION ONE (1) ___ Respondent does not dispute the allegations of fact contained in the Administrative Complaint and waives Respondent’s right to object or to be heard. Respondent understands that by waiving Respondent’s rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) ___ Respondent does not dispute and Respondent admits the allegations of fact in the Administrative Complaint, but Respondent does wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time Respondent will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3)____—- Respondent does dispute the allegations of fact contained in the Administrative Complaint and Respondent requests a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If Respondent chooses OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Respondent’s 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 Respondent’s right to a hearing, Respondent’s Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of the Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. If Respondent has elected either OPTION TWO (2) or THREE (3) above and if Respondent is interested in discussing a settlement of this matter with the Agency, please also mark and check this block. ( )e 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 RESPONDENT RECEIVES A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY PINTS (hicuse sigh anu didi dis yOu Cusicin wUUIESS., Respondent (Licensee) Address: License. No. and facility type: PLEASE RETURN YOUR COMPLETED FORM TO: Agency for Health Care Administration, Attention: Ursula Eikman, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Fl, 32308 Phone No.

Docket for Case No: 03-001550