STATE OF FLORIDA LET AGENCY FOR HEALTH CARE ADMINISTRATION nf, ~§ 15): 23 ad wh A, J, SUBACHAN II, INC. d/b/a BRIARWOOD MANOR AKA BRIARWOOD MANOR RETIREMENT, Petitioner, AHCA No.: 2008004923 DOAH No.: 05-2611 vs, RENDITIO. a -O5- -Se. STATE OF FLORIDA, AGENCY FOR N'NO.: AHCA-05- O48 -s-o1¢ HEALTH CARE ADMINISTRATION, Respondent. FINAL ORDER State of Florida, Agency for Health Care Administration (hereinafter “AHCA” or “agency”, having reviewed the Notice of Intent To Deny dated June ‘to, 2005 and the Amended Notice Of Intent To Deny dated August 15, 2005 addressed to Briarwood Manor (hereinafter, “Briarwood Manor”), attached hereto and incorporated herein as Exhibit 1 and Exhibit 2, and all other matters of record, finds and concludes as follows: FINDINGS OF FACT 1. The Agency issued a Notice Of Intent To Deny dated June 10, 2005, (attached as Exhibit 1) and an Amended Notice Of Intent To Deny, dated August 15, 2005, (attached as Exhibit 2) notifying Briarwood Manor of its intent to deny their application for licensure as an assisted living facility 1 due to failure to correct deficiencies as a resuit of a follow-up survey and to pay outstanding fines. 2. On July 20, 2005, Briarwood Manor ‘submitted an Amended Request for a Formal Hearing, which is attached hereto and incorporated herein as Exhibit 3. 3. On September 2, 2005, the Assisted Living Unit sent a letter rescinding the Notice of Intent To Deny and the Amended Notice Of Intent To Deny, which is attached hereto as Exhibit 4. The letter of rescission renders the above-styled case moot. 4. °~On September 16, 2005, the parties executed an Amended And Superseding Joint Motion To Relinquish Jurisdiction And To Close The Agency File, which motion is attached hereto as Exhibit 5. ORDERED: . 1. AHCA rescinded the Notice Of Intent To Deny and the Amended Notice of Intent To Deny which renders the above-styled case moot. 2. The above-styled case is hereby dismissed. DONE and ORDERED this HT day of Heplembae, 2005, in Tallahassee, Leon County, Florida. Alan Levine,\Secretary Agency for Health Care Administratio 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 AGENCY CLERK AND A SECOND COPY, 2 ALONG WITH FILING FEE AS PRESCRIBED BY LAW, IN THE DISTRICT COURT OF APPEAL WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Lourdes A. Naranjo, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52™ Terrace - Suite 103 Miami, Florida 33166 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bldg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive - Mail Stop # 14 Tallahassee, Florida 32308 (Interoffice Mail) Jan Mills Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) John G. Van Laningham Administrative Law Judge Agency for Health Care Administration 1230 Apalachee Parkway Tallahassee, Florida 32399 (U. S. Mail) Donna Szczebak O'Neil, Esq. 301 East Commercial Blvd Ft. Lauderdale, Florida 33334 (U.S. Certified Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy of the foregoing was mailed to the above-named addressees on this .S* day of <2#6éer , 20087 Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32303 850-922-5873 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR : ALAN LEVINE, SECRETARY CERTIFIED MAIL RETURN RECEIPT REQUESTED Certified Article Number Article Number mame d®, 200° aa RE: CC# 2005004927 PLEO 3901 84a 476 209? Andy Subachan SENDERS RECORD. Briarwood Manor 5621-5631 N.W. 28th Street Lauderhill, FL 33313 NOTICE OF INTENT TO DENY Dear Mr. Subachan: OS! od 9~ 100 S002 It is the decision of this Agency that Briarwood Manor renewal application for an assisted living facility be DENIED. The Specific Basis for this determination is: * The applicant's failure to meet minimum licensure standards. During the license renewal survey conducted on February 25, 2005, ten (10) Class III deficiencies were cited in the required compliance areas of Admissions Criteria Standards, Staffing Standards, Medication Standards, and Physical Plant Standards. During the follow-up survey conducted on April 4, 2005, three (3) Cl jencies cited during the February 25, 2005 survey were found to be uncorrected in the required compliance areas of Staffing Standards, and Physical Plant Standards. A second follow-up survey was conducted on June 6, 2005. Two (2) of three (3) Class Hl deficiencies recited during the April 4, 2005 follow-up survey were found to remain uncorrected in the required compliance area of Physical Plant Standards. Failure to meet minimum license standards is grounds for denial, pursuant to Section 58A-5.023(1)(b), Florida Administrative Code (F.A.C.), and Section 400.414 (1)(i), Florida Statutes @S.). e In addition, the applicant failed to meet minimum license requirements pursuant to Section 408.831(1), (F.S.), and Section 400.417(3), (F.S.) which states that a license for the operation of a facility shall not be renewed if the licensee has any outstanding fine (s) assessed pursuant to this part which are in final order status. The fines were requested in an omissions letter dated May 17, 2005. To date, the applicant has not paid the following fines in final order status: $750 AHCA NO: 2004010182, $750 AHCA NO: 2005001298, $750 AHCA NO: 2005000505, $750 AHCA NO: 2004011445, $1,250 AHCA NO: 2004011444, 2727 Mahan Drive # Mail Stop #30 Tallahassee, FL 32308 Visit AHCA Online at ahca.myflorida.com ae ary ” EXHIBIT | Briarwood Manor June 10, 2005 Page 2 EXPLANATION OF RIGHTS Pursuant to Section 120.569, Florida Statutes, (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), E.S., 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 ELECTION AND EXPLANATION OF RIGHTS FORMS Sincerely, Bureau of Long Term Care Services AG/dn Copy to: West Palm Beach Field Office - 10 Administrator, District 10, Dept. of Children and Families LTICOC District 10 DOEA, Tallahassee Wendy Adams, General Counsel Office JES BUSH, GOVERNOR ; . ALAN LEVINE, SECRETARY CERTIPIED MAIL RETURN RECEIPT REQUESTED Certified Article Number August 15, 2005 2 -7UbD S50L 849 LES 7449 RE: CCH 2005004927 4 SENDERS RECORD Andy Subachan Briarwood Manor 5621-5631 N.W, 28th Street Lauderhill, FL 33313 AMMENDED NOTICE OF INTENT TO DENY Dear Mr: Subachan: 1 od 4~ 190 Seo ‘unl = It is the decision of this Agency that Brarwood Manor renewal application for an assisted’ iving facility be DENIED. 0S The Specific Basis for this determination is: * The applicant’s failure to meet minimum licensure standards. During the license renewal survey conducted on February 25, 2005, ten (10) Class Il deficiencies were cited in the required compliance areas of Admissions Criteria Standaxds, Staffing Standards, Medication Standards, and Physical Plant Standards. During the follow-up survey conducted on April 4, 2005, three (3) Class II deficiencies cited during the February 25, 2005 survey were found to be uncorrected in the required compliance areas of Staffing Standards, and Physical Plant Standards. A second follow-up survey was conducted on June 1, 2005. Two (2) of three (3) Class IN deficiencies recited dunng the April 4, 2005 follow-up survey were found to remain uncorrected in the required compliance area of Physical Plant Standards. Failure to meet minimum license standards is grounds for denial, puxsuant to Section 584-5.023(1)(b), Florida Administrative Code (F.A.C.), and Section 400.414 (1)(i ), Florida Statutes (F.S.). = In addition, the applicant failed to meet minimum license requirements pursuant to Section 408.831(1), (F.S.), and Section 400.417(3), (F.S.) which states that a license for the operation of a facility shall not be renewed if the licensee has any outstanding fine (s) assessed pursuant to this part which are in final oryler status, The fines were requested in an omissions letter dated May 17, 2005. To date, the applicant has not paid the following fines in final order status: $750 AHCA NO: 2004010182, $750 AHCA NO: 2005001298, $750 AHCA NO: 2005000505, $750 AHCA NO: 2004011445, $1,250 AHCA NO: 2004011444, $750 AHCA NO: 2004005429. : Visit ANCA Online at ahea myflerida.com 2727 Maban Drive » Mail Stop #30 Tallahesscc, PL 32308 awe “EXHIBIT = Briarwood Manor August 15, 2005 Page 2 EXPLANATION OF RIGHTS SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS Sincerely, Bureau of Long Term Care Services AG/dn Copy to: West Palm Beach Field Office - 10 : Administrator, District 10, Dept. of Children and Families LTCOC District 10 DOEA, Tallahassee Wendy Adams, General Counsel Office Lourdes Naranjo, Assistant General Counsel STATE OF FLORIDA IN RE: The Request for Hearing concerning: FRAES NO.: 2005004927" BRIARWOOD MANOR RETIREMENT Respondent. AMENDED REQUEST FOR FORMAL HEARING COMES NOW, BRIARWOOD MANOR RETIREMENT, by and through its undersigned counsel and files this Amended Request for Formal Hearing: 1. A.J. SUBACHAN HI, INC, a Florida corporation, is doing business as BRIARWOOD MANOR RETIREMENT at 5621-5631 NW 28" Street, Lauderhill, FL 33313. 2. Florida Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #30, Tallahassee, FL 32308 mailed a Notice of intent to Deny, dated June 10, 2005, to BRIARWOOD MANOR RETIREMENT and stated that the Agency denied BRIARWOOD MANOR RETIREMENT'S renewal application for licensure. This certified mailing was received on June 16, 2005. 3, BRIARWOOD MANOR RETIREMENT'S pro se response requesting a formal hearing, was received by the Agency for Health Care Administration on June 30, 2005. 4. © Qn duly 6, 2005, Florida Agency for Health Care Administration issued and mailed an Order of Dismissal Without Prejudice Pursuant to Sections 120.54 and 120.569, Florida Statutes and Rules 28-106.111 and 28-106.201, Florida Administrative Cade to Allow for Amendment and Resubmission of Petition, denying BRIARWOOD MANOR RETIREMENT'S request for a formal hearing as legally insufficient. 5. All issues of material fact are in dispute. 6. This is 8 request for a formal hearing. EXHIBIT na 7, None of the alleged deficiencies, in the aggregate or individually, seriously affect the health, safety or welfare of the facility resident, many of whom have been residents at the facility In excess of six (6) years and for as tong as thirteen (13) years. 8. All alleged deficiencies are Class Hl deficiencies, 9, The ten (10) alleged deficiencies of the 2/25/05 survey were corrected by the 4/4/05 follow up survey. The three (3) alleged deficiencies of the 4/4/05 survey were corrected by the 6/1/05 second follow up survey, The two (2) alleged deficiencies of the 6/1/05 survey have been corrected. Although the alleged uncorrected deficiencies concern physical plant, none are the same alleged ’ deficiency. , 40, The facility does maintain a clean physical plant free of accumulation of dirt, dust and debris and is maintained to provide for the safe care of all residents and is in good repair. 11. All fastening devices at the facility are secure, 12. The facility ensures that windows, doors and appliances are in good repair. 43, The facility ensures that all residents have a complete health assessment/medical examination report in their records. 14. ° The facility maintains proper medical information in the residents’ files. 16. The facility is properly staffed. 16, The facility ensures that resident medications, both prescription and over the counter, kept in the residents’ rooms, are lacked when the resident Is absent or In a secure place In the room and out of sight of other residents. 17. Centrally stored medications are kept in a locked cabinet, locked cart or other locked storage receptacle, room or area at all times. 418, Discontinued medications are properly stored separately from medications in current use. 19. The facility maintains written records, properly updated, of any significant changes in the residents’ normal appearance or state of health, any illnesses which resulted in medical altention, major incidents, changes in the method of medication administration or other changes which result in addiliona! services, 20, Furniture and furnishings are in good repair and clean, upholstery is in tact and all fastening devices are secure. ai. All fines were paid. . 22, A denial of relicensure of the facility will substantially affect BRIARWOOD MANOR RETIREMENT'’S interest by closing down its business, forfeiting all of its consistent efforts since 2002 to rehabiliiate the limited mental health facility and forcing the relocation of the SSI residents whose mental states are fragile and who suffer from diseases which include, but are not limited to schizophrenia and depression. 23, BRIARWOOD MANOR RETIREMENT'S license should be renewed because all alleged deficiencies ‘on each survey were corrected and none are repeat deficiencies. Because the tenants are destructive, new alleged deficiencies were cited. At the time of the last survey, the facility was undergoing renovation, thus being the cause of same of the alleged deficiencies — for example, a framing strip was nat in place because it had to be removed to Install the new floor tile. The facility now has a full time maintenance person whose duties include overseeing the physical plant and monitoring any debris being dumped on the premises by neighbors. 24, None of the violations are sufficient to warrant a denial of licensure pursuant to FS 400.414, 25. BRIARWOOD MANOR RETIREMENT is in substantial compliance with the requirements of Chapter 400, Part Il! and Chapter 58A-5, F.A.C, far Assisted Living Facilities, 26. BRIARWOOD MANOR RETIREMENT is interested in discussing settlement of this matter. WHEREFORE, undersigned counsel requests that a formal hearing be granted and BRIARWOOD MANOR RETIREMENT’S license be renewed. |! HEREBY CERTIFY that a true and correct copy of the foregoing has been faxed to 850 921 0158 and furnished by FedEx to the Agency far Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, FL 32208, this 20 day of July, 2005, ~ DONNA SZCZEBAK O'NEIL, ESQUIRE Attorney for Petitianer DONNA SZCZEBAK O'NEIL, P.A. Florida Bar Number: 241067 301 East Commercial Boulevard Fort Lauderdale, Florida 33334 Telephone: (954) 776-0887 Bafgo/fceeog tse tt —— ne ( t nN . ~ — . JEB BUSH, GOVERNOA ALAN LEVINE, SECRETARY CERTIFIED MAIL RETURN - RECEIPT REQUESTED Certified Article Number September 2, 2005 8 P SENDERS RECORD Andy Subachan, Administrator ‘ 2 Briarwood Manor a 5621 - 31 NW 28" Street po Lauderhill, FL 33313 5 RE: CC# 2005004927 = on OQ Dear Mr. Subachan: The Agency for Health Care Administration has taken action to rescind the June 10, 2005 and the amended August 15, 2005 Notice of Intent to Deny the renewal application for the above assisted living facility (ALF). The uncorrected deficiencies from the follow up survey conducted on June 1, 2005 have been corrected and the following fines in final order status have been paid: $750 AHCA NO: 2004010182, $750 AHCA NO: 2005001298, $750 AHCA NO: 2005000505, $750 ; AHCA, NO: 2004011445, $1,250 AHCA NO: 2004011444, $750 AHCA NO: 2004005429. The facility ‘is currently in compliance with the requirements of Chapter 400, Part IT Florida Statutes (F.S.), and Chapter 58A-5 Florida Administrative Code (F.A.C), for ALF’s. A Standard license with Limited Mental Health is being issued at this time for the continued operation of your facility. This license will be sent to you under separate cover. , If you need further assistance, please call David Negrete at (850) 487-2515. anger, Assisted Living Uni Bureau of Long Term Care Services AG/dn oe, Copy to: West Palm Beach Field Office Manager Long Term Care Ombudsman Council, District 10 Administrator, Children and Families, District 10 Department of Elder Affairs, ALF Program, Tallahassee’ Wendy Adams - Office of General Council EXHIBIT 2727 Mahan Drive * Mail Scop # 30 " Tallshagsee, FL 32308 Visit AHCA online ar www fdhe.state jl.us STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION A.J.SUBACHAN II, INC. d/b/a BRIARWOOD MANOR AKA BRIARWOOD MANOR RETIREMENT, a Case No. 05-2611 & «ge Cees Petitioner, 2 4 1 Vv. co UD STATE OF FLORIDA a AGENCY FOR HEALTH CARE om] ADMINISTRATION, Respondent. AMENDED AND SUPERSEDING JOINT MOTION TO RELINQUISH JURISDICTION AND TO CLOSE THE AGENCY FILE COMES NOW the Petitioner, A.J. Subachan II, Inec., d/b/a Briarwood Manor aka Briarwood Manor Retirement, and the Respondent, the Agency for Health Care Administration, by and through their respective counsel, and file this Amended and Superseding Joint Motion to Relinquish Jurisdiction and To Close the Agency File and state as follows: 1. The Parties are filing this Amended and Superseding Joint Motion to correct the name of Petitioner in the pleadings in this case. The correct name of Petitioner is “A.J. Subachan II, EXHIBIT 5 Inc. d/b/a Briarwood Manor” and not ‘Briarwood Manor Retirement”, even though both names have been used in the pleadings. The Parties would like to correct this confusion and state that it is understood and agreed by the parties that the correct name of Petitioner is “A.J. Subachan II, Ine. d/b/a Briarwood Manor”. 2. Petitioner paid the outstanding fines reflected in the Notice of Intent to Deny and the Amended Notice of Intent to Deny. Therefore Respondent has rescinded its Notice of Intent to Deny and its Amended Notice of Intent to Deny and the issue that is the subject matter of this proceeding is now moot. 3. Accordingly, the parties request that the Division of Administrative Hearings relinquish jurisdiction for the Formal Administrative Hearing at this time. The Parties also request that the Agency Clerk close its file. 4. Petitioner voluntarily dismisses its Petition for a Formal Administrative Hearing. 5. Each party will bear its own attorney’s fees and costs. WHEREFORE, Petitioner and Respondent respectfully request that the Administrative Law Judge enter an order granting the Amended and Superseding Joint Motion to Relinquish Jurisdiction and To Close the File. Us i0f 2 Se ee ———roe sep-15-2005 14:04 AHCA if. DEPARTMENT C P.84 . _ Respectfully submitted on this [® day of *, 2005. (2-7, G lemcoy houxdes A. Naranjo, Bsquire assistant General Counsel Agency for Health Administration 9350 N.W. 52%° Terrace Miami, Florida 33166 (305) 470-6800 LT 47 ee Donna Szezebak O'Neil, Baquire ‘Attorney for Petitioner Briarwood Manor aka Briarwood Manor Retirement 301 E. Commercial Blvd. Ft. Lauderdale, Florida (954) 776-0887 (954) 776-0984 fax CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and coxrect copy of the _ foregoing was faxed to John Van Laningham, Administrative Law Judge, and to the Clerk, Division of Administrative Hearing, The DeSoto Building, 1230 Apalachee Parkway, Tallahassee, Florida 32399-3060, and to Donna Szczebak O'Neil, Esquire, 301 East Commpgct a” Boulevard, Fort Lauderdale, Plorida 33334, on this Lie ay of ' , 2005. al {frdes A. Naranjo, Esquire

Docket for Case No: 05-002611