CU~(18% STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Rrory icv PH bs gs AGENCY FOR HEALTH CARE ADMINISTRATION, oe Petitioner, AHCA No.: 2004001262” Return Receipt Requested: v. 7002 2410 0001 4237 0423 7002 2410 0001 4237 0430 MY GUARDIAN ANGEL ALF, INC., d/b/a MY GUARDIAN ANGEL ALF, INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this Administrative Complaint against My Guardian Angel ALF, Inc., d/b/a My Guardian Angel ALF, Inc., (hereinafter “My Guardian Angel ALF”), pursuant to chapter 400, part III, and section 120.60, Florida Statutes, (2002), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the license pursuant to Sections 400.414({1) (a) and 400.414(1)(e), Fla. Stat., for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part III, Florida Statutes (2002). 3. venue lies in Miami Dade County, pursuant to Rule 28- 106.207, Florida Administrative Code (2002). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2002), and Chapter 58A-5 Florida Administrative Code. S. My Guardian Angel ALF operates a 6-bed assisted living facility located at 15088 S.W. 71%" Lane, Miami, Florida 33193. My Guardian Angel ALF is licensed as an assisted living facility, license number AL9725; with the expiration date of December 15, 2005. My Guardian Angel ALF was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I MY GUARDIAN ANGEL FAILED TO ENSURE THAT AT LEAST ONE STAFF MEMBER TRAINED IN FIRST AID AND CPR IS IN THE FACILITY AT ALL TIMES 58A-5.019(4) (a)4, F.A.C. (STAFFING STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. A desk review was conducted on 01/26/2004, after additional information was obtained from the Miami Dade Fire Department. Based on the new information received, the following deficiency was changed from Class II to Class I. 8. The information revealed that only the “caretaker” was present at the facility on 10/07/2003 when resident #4 choked on food. Record review revealed that the caretaker did not have documentation of training in First Aid and CPR. The facility did not have at least one staff member trained in First Aid and CPR within the facility at all times. The facility intentionally left the residents without a staff member trained in First Aid and CPR, and as such, placed the residents’ health, safety and welfare at risk. This is evidenced by the fact that resident #4 choked to death in the absence of any trained staff person being present. 9. Based on the foregoing, My Guardian Angel ALF violated Section 58A-5.019(4) (a)4, F.A.C., a Class I violation, which carries, in this case the revocation of license. PRAYER FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: i. Make factual and legal findings in favor of the Agency on the Count I. 2. Revoke the license pursuant to Chapters 400.414(1) (a), and 400.414(1) (e), Fla. Stat. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration. Attn: Lealand McCharen, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, Telephone (850) 922-5873. 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. son BE. Rodney Assistant General Co Agency for Health Cafe Administration Spokane Building, Suite 103 8350 N. W. 52™ Terrace Miami, Florida 33166 sel Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 537° Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Adult Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Osmy T. Hidalgo-Mosquera, Administrator, My Guardian Angel ALF, Inc., 15088 S.W. 71%* Lane, Miami, 33193, and Alberto Davila, Registered Agent, 15088 S.W. 71%* Lane, Miami, Florida 33193 on this 23 ‘ day of 2006 Nelson Rodney — 5

Docket for Case No: 04-001188