STATE OF FLORIDA ? AGENCY FOR HEALTH CARE ADMINISTRATION SYLVIA’S a RETIREMENT HOME, INC., . “ d/b/a SYLVIA’S De. RETIREMENT HOME, eg Petitioner. Boor Bp 7 a 7 &, AHCA NO: 2004007120: DOAH NO: 04-3800 PHYN -C las RENDITION NO.: AHCA-05-QXG}-S-OLC vs. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. FINAL ORDER The Agency for Health Care Administration, having entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, determines as follows: The attached Stipulation and Settlement Agreement is approved and adopted as a part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. THEREFORE it is ORDERED and ADJUDGED: 1. That the parties hereto are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. A fine of $375 is hereby imposed upon SYLVIA’S RETIREMENT HOME, INC. d/b/a SYLVIA’S RETIREMENT HOME. The fine is due and payable within thirty (30) days of the date of rendition of this Final Order. 3. The above-captioned case is dismissed. 4. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this Case number, should be sent directly to: Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, Bldg #2, Mail Stop Code #14 Tallahassee, Florida 32308 5. Unpaid fines will be subject to statutory interest, and may be collected by all methods legally available. _-~ DONE and ORDERED this LT day of 200%, in Tallahassee, Leon County, Florida. Alan Levine) Secretary i ealth Care Administration Agency for A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Elizabeth Dudek, Deputy Secretary Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive, Bldg #2, Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail) Sylvia D. Williams, Administrator Sylvia’s Retirement Home 1823 NW 94 Street Miami, Florida 33147 (U.S. Mail) Timothy B. Elliott Senior Attorney (Interoffice Mail) Wendy Adams Facilities Intake Unit (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named persons and entities by U.S. Mail, or the method designated, on this 8 day or Bdguaed , 2000. op Iency 2727 Mahan Drive, Building #3, MSC #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION SYLVIA’S RETIREMENT HOME, INC., d/bla SYLVIA’S RETIREMENT HOME, Petitioner, vs. AHCA NO. 2004007120 DOAH NO. 04-3800 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Respondent, Agency for Health Care Administration ("Agency") through their undersigned representatives, and SYLVIA’S RETIREMENT HOME, INC., d/b/a SYLVIA’S RETIREMENT HOME ("Petitioner") pursuant to Sec. 120.57(4), Florida Statutes each individually, a "party," collectively as "parties," hereby enter into this Stipulation and Settlement Agreement ("Agreement") and agree as follows: WHEREAS, Petitioner operates an assisted living facility licensed pursuant to Chapter 400, Part Ill, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Petitioner, pursuant to Chapter 400, Part Ill, Florida Statutes (2004); and Chapter 58A-5, Florida Administrative Code (2004); and WHEREAS, by certified mail, the Agency served Petitioner a Notice of Intent to impose Fine on August 17, 2004, notifying the party of its intent to impose an administrative fine of $500; and WHEREAS, Petitioner requested a formal administrative hearing in documentation received by the Agency on August 30, 2004; and WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Petitioner agrees to a withdrawal of its Request for Formal Hearing; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes (2004); and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. Provided, however, that no agreement herein, shall be deemed a waiver by either party of its right to judicial enforcement of this stipulation. 4. Upon full execution of this Agreement, Petitioner agrees to pay $375, to the Agency within 30 days of the entry of the Final Order. Venue for any action brought Page 2 of 5 to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 5. By executing this Stipulation, Petitioner does not admit, and the Agency asserts the validity of, the allegations raised in the Notice of Intent to Impose Fine referenced herein. The Agency agrees that it will not impose any further penalty against Petitioner, a result of its failure to submit the required 15-day adverse incident report (DOEA form 3180-1025) in January of 2004. 6. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement. 7. Each party shall bear its own costs and attorney fees. 8. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 9. Petitioner, for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this Agreement, by or on behalf of Petitioner or related facilities. 10. | The Agency for Health Care Administration, does hereby discharge Petitioner, and its agents, representatives, and attorneys of and from all claims, Page 3 of 5 demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, except those precluded explicitly within this Agreement, arising out of or in any way related to this matter and the Agency's actions in this matter, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of the Agency for Health Care Administration. 41. | This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph nine (9) of this Agreement. 12. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 13. | This Agreement contains the entire understandings and agreements of the parties. 14. This Agreement supercedes any prior oral or written agreements between the parties. 15. A facsimile signature contained herein shall be as valid and binding as an original signature thereof. THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK Page 4 of 5 NOV-16-2084 15754 AGENCY HEALTH CARE ADMIN 858 921 8158 Pa? 46. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement: SYLVIA D. WILLIAMS, Administrator, Deputy Secr¢tary, Division of Health Quality Assurance, for Agency for Health Care Administration Syivia’s Retirement Home 2727 Mahan Dr., Mail Stop 9 4823 NW 94 Street Tallahassee, FL 32308 Miami, FL 33147 DATED: Y, OS DATED: Upreondet AG, AOOY General Counsel, Agency for Health Care Administration 2727 Mahan Dr., Mail Stop 3 Tallahassee, FL. 32308 DATED: LA Lhs LOG Page 5 of 5 , TOTAL P.Q7 ted 6+@0-O£F-+S6 wauseg BtArhsS dstt#O #0 G2 “ON

Docket for Case No: 04-003800