(4-032 STATE OF FLORIDA © AGENCY FOR HEALTH CARE ADMINISTRATION Og Jay Sf) <8 Py STATE OF FLORIDA . #26 AGENCY FOR HEALTH CARE Ps ADMINISTRATION, fos Petitioner, CASE NO: 2003007495 vs. SHADY OAKS LIVING CENTER, INC., 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 SHADY OAKS LIVING CENTER, INC., (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of five hundred dollars ($500) pursuant to Section 400.419(1) (c) Florida Statutes. 2. The Respondent is cited for the deficiency set forth below as a result of a follow-up survey completed on August 18, 2003. The violation cited is one (1) uncorrected Class III deficiency, originally cited at a Complaint Investigation on or about May 22, 2003. ag page 3 missing. Ait wil freward “Om JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. PARTIES 5. AHCA, Agency for Health Care Administration, State of Florida 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 2208 East 138°" Avenue, Tampa, FL 33612. 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 ENSURE THAT PEELING PAINT OR WALLPAPER, MISSING CEILING OR FLOOR TILES, OR TORN CARPETING SHALL BE REPAIRED OR REPLACED. VIOLATING RULE 58A-5.023(1) (b), F.A.C., UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. This is a violation of Rule 58A-5.023(1) (b), Florida Administrative Code which requires that peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. 14. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c) Florida Statutes (2002). WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order relief with fines against the Respondent pursuant to Section 400.419(1) (c) Florida Statutes in the amount of five hundred dollars ($500.00). The Respondent 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: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Wayne “ly. AHCA * Fla. Bar No. 0136440 525 Mirror Lake Drive North, 330L St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Joseph W. Joseph, Administrator/Registered Agent for Shady Oaks Living Center, Inc., 2208 East 138 Avenue, Tampa, FL 33613, Return Receipt No. 7003 1010 0003 4303 8500 by U.S. Certified Mail on November U/ , 2003. Copies furnished to: Joseph W. Joseph, Administrator Registered Agent for Shady Oaks Living Center, Inc. 2208 East 138°" Avenue Tampa, FL 33613 (Certified U.S. Mail) Wayne D. Knight, Esq. Senior Attorney 525 Mirror Lake Drive Suite 330L St. Petersburg, Fl 33701

Docket for Case No: 04-000332