FLED HCA GENCY CLERK 2004 AUG -2 A & 29 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO. 2004003669 : DOAH NO. 04-2142 -- sony INC. d/bla SUSANNA WESLEY ALDERSGATE HEALTHCARE, p an oa HEALTH CENTER, : - Respondent. are ! a ee FINAL ORDER Having reviewed the Notice of Intent to Impose Fine for the above-styled case, and all other matters of record, the Agency for Health Care Administration (“Agency”) finds and concludes as follows: FINDINGS OF FACT 1. The Agency issued a Notice of Intent to Impose Fine dated April 22, 2004 upon Respondent (Ex. 1). 2. Respondent requested a formal hearing on June 3, 2004 (Ex. 2). 3. The Agency rescinded the Notice to Impose Fine on July 8, 2004 (Ex. 3). 4. Based on the above-cited facts, DOAH issued an Order Closing File (Ex. 4). CONCLUSIONS OF LAW 1. The Agency has jurisdiction over Respondent pursuant to the provisions of Chapter 400, Part Il, and Section 120.569, Florida Statutes. AHCA No. 2004003669 Final Order Page 1 of 3 2. The Agency rescinded the Notice of Intent to Impose Late Fine in the above-mentioned case, removing grounds for further proceedings. Based on the foregoing findings of fact and conclusions of law, it is ORDERED: 4. The Notice of Intent to Impose Late Fine in the above-styled case is hereby rescinded. 2. The issue is now moot. DONE and ORDERED this PE day of gate. 2004 in Tallahassee, Leon County, Florida. Alan Levine)Secretary Agency for Health Care Administration Copies furnished to: Iris Broun, Executive Assistant Susanna Wesley Health Center 5300 West 16" Avenue Hialeah, FL 33012 Michael M. Parrish, Administrative Law Judge Division of Administrative Hearings The DeSoto Building 4230 Apalachee Parkway Tallahassee, FL 32399 Elizabeth Dudek, Deputy Secretary Agency for Health Care Administration (Interoffice Mail) Joanna Daniels, Assistant General Counsel Agency for Health Care Administration (Interoffice Mail) AHCA No. 2004003669 Final Order Page 2 of 3 Wendy Adams, Regulatory Consultant Agency for Health Care Administration (Interoffice Mail) Jean Lombardi, Office of Finance & Accounting Agency for Health Care Administration (interoffice Mail) CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing was mailed to the above-named addressees by U.S. Mail or other method designated on this Z day of , 2004. 2727 Mahan Drive, Building #3, MS #3 Tallahassee, FL 32308 (850) 922-5873 AHCA No. 2004003669 Final Order Page 3 of 3 @ | mre eyy oo pugek 2 2°26 \ MARY PAT MOORE, INTERIM SECRETARY _ yt JEB BUSH, GOVERNOR * Yo ruake 9 : Certified vata Number April 22, 2004 auL0 3701 64h yo% 8793 z SENDERS 1 =4010)51°) Administrator Susanna Wesley Health Center 5300 W. 16" Avenue Hialeah, FL 33012 NT TO IMPOSE LATE FINE #2004003669 NOTICE OF INTE Dear Administrator: A fine of $5,000 is hereby imposed due to the late filing of the application for annual licensure renewal for Susanna Wesley Health Center: The application for license renewal was due to the Agency for Health Care Administration by 4/01/04. However, the application was received, 4/19/04, eighteen (18) days late. Pursuant to Section 400.111, Florida Statutes, (F.S.) the Agency must assess @ fine for license renewal applications that are not received at least ninety, (90) days prior to the license expiration date. A fee shall be in an amount equal to 50% of the licensure fee in effect on the last preceding regular renewal date and is assessed for each day peyond the license due date, UP to a maximum of $5,000. PAYMENT SHOULD BE SENT TO: (if paid within 21 days of receipt of notice) Agency for Health Care Administration Long Term Care Unit, MS-33 2727 Mahan Drive Tallahassee, FL 32308 (Please include a copy of this Notice of Intent) EXHIBIT ) Susanna Wesley Health Center April 22, 2004 Page 2 EXPLANATION OF RIGHTS . Pursuant to Section 120.569, F.S., you have the right to request an administrative hearing. In, order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), FS., your 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. SEE ATTACHED EXPLANATION OF RIGHTS AND ELECTION OF RIGHTS FORM Sincerely ' CaraLee S. Stames, Program Manager Long Term Care Unit Health Facility Regulation cc: , Betty Reecy, LTC unit ee jun O3 04 04:07P The quality Hanagement gusvuuLEe ' ’ ALDERSGATE HEALTHCARE, ING. D/B/A SUSANNA WESLEY HEALTH CENTER DOR IMED rue abe Fe 22s RECEIVED - ia Facsmile: (850) 921-0158 GENERAL COUNSEL ; Lealand L. McCharen iy gency Clerk ' Ji N 0 3 2004 tate of Florida, AHCA ; 72] Mahan Drive, MS #3 Agency for Health allahassee, FL 32308 Care Administration e: The Request for Hearing : AHCA No. 2004003669 hank you for talking to me on May 27, 2004 and allowing me to submit my response to you via csimile. We agreed at the time that the 15 day deadline would be June 4, 2004. The following e my responses: ) All petitions filed under these rules shall contain: (a) The name and address of each agency affected and each agency’s file or identification number, if known. AHCA, 2727 Mahan Drive, MS #3, Tallahassee, FL 32308 AHCA, Long Term Care Unit, MS #33, Tallahassee, FL 32308 #2004003669 7 (b) The name, address, and telephone number of the petitioner; the name, address, and telephone number of the petitioner’s representative, if any, which shall be the address for service purposes during the course of the proceeding; and an explanation of how the petitioner’s substantial interests will be affected by the agency determination; Petitioner: Susanna Wesley Health Center, 5300 W. 16™ Avenue, Hialeah, FL 33012 Representative: K.C. Cross {same as above) Address for Service: (same as above (c) Statement of when and how the petitioner received notice of the agency decision; Notice received via mail “Return Services Requested” on May 24, 2004. 2eTEL (305) 556-3500 * FAX: (305) 821-1 407 EXHIBIT 1% —_——eeeoeo 5300 W. 16™ AVENUE, HIALEAH, FL 3301 Jun a3 Of a4:08pP he Quality Management wove --- (d) A statement of all dispute issues of material fact. If there ® Fone, the petitioner must so indicate, ' See (e) below. ce) A concise statement of the ultimate facts alleged, sncluding the specific facts the petitioner contends warrant reversal or modification of the agency’s proposed action; ‘ Application for renewal was due April 1, 2004 (90 days prior to expiration of license). License for CHOW was only issued and faxed to us on April 9, 2004. (See attached) Our application for renewal in the new name was mailed out on April 14, 2004. On April 1, 2004 it was not feasible to renew a license that we had not yet received. See Fax coversheet dated April 9, 2004 when CHOW license was faxed to us. (f) A statement Of the specific mules or statues the petitioner contends require reversal or modification of the agency’s proposed action, Order of Dismissal Without Prejudice and dismissal of fine. (B) A statement of the relief sought by the petitioner, stating precisely the action petitioner wishes the agency to take with respect to the agency’s proposed action. Order of Dismissal Without Prejudice and dismissal of fine. Reasom listed in (e) above. (3) The entity for which a hearing is requested appears to be a corporation, but there is no showing that the person asking for the hearing is either an attorney or a person authorized by the corporation to act on its behalf. K.C. Cross, $300 West 16" Avenue, Hialeah, FL 33012 . If you need addition information please call me at (305) 556-3500 Ext. 6054. Sincerely, Vis B fon Jris Broun Executive Assistant Attachs: JEB BUSH, GOVERNOR July 8, 2004 Administrator | Susanna Wesley Health Center 5300 W. 16" Ave. Hialeah, FL 33012 RE: Rescinding Late Fine Assessment #2004003669 ' . cy Dear Administrator: The late fine assessment imposed for the above facility in our letter to you dated April 22, 2004 is hereby rescinded. : If you have any questions, please call Betty Reecy in the Long Term Care Unit at — (904) 488-5861. _ \ ‘Singerely, iy She Cara Starnes, Program Manager Long Term Care Unit Health Facility Regulation cc: Wendy Adams, Legal MS-3 Betty L Reecy, LTC Unit File EXHIBIT a Le i=) Visit AHCA online at www.fdhe.state.fl.us 2727 Mahan Drive « Mail Stop #33 Tallahassee, FL 32308 STATE OF FLORIDA RECEIVED DIVISION OF ADMINISTRATIVE HEARINGS GENERAL CGUNSEL JUL 16 2004 Agency for Health Care Administration AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 04-2142 ALDERSGATE HEALTHCARE, INC., a/b/a SUSANNA WESLEY HEALTH CARE, Respondent. ee ee ORDER CLOSING FILE This cause having come before the undersigned on Respondent’s Suggestion of Mootness and Motion to Close File filed July 14, 2004, and the undersigned being fully advised, it is, therefore, ORDERED that: 1. The final hearing in this cause scheduled for August 13, 2004, is hereby cancelled. 2. The file of the Division of Administrative Hearings in the above-captioned matter is hereby closed. EXHIBIT

Docket for Case No: 04-002142