STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: v. Return Receipt Requested: ' 7002 2410 0001 4234 6800 RENAISSANCE RETIREMENT COMMUNITY, 7002 2410 0001 4234 6815 INC., d/b/a THE PLAZA SOUTH, Respondent. OS- ASTS / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this administrative complaint against Renaissance Retirement Community, Inc., d/b/a Plaza South (The), hereinafter (“Plaza South”), pursuant to Chapter 400, Part III and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine o£ $500.00 pursuant to Sections 400.414 (1) (a) and 400.419(1) (c), Florida Statutes for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 3. Venue lies in Miami-Dade County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. 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 (2004) and Chapter 58A-5 Florida Administrative Code. 5. Plaza South operates a 50-bed assisted living facility located at 1690 Collins Avenue, Miami Beach, Florida 33139. Plaza South is licensed as an assisted living facility under license number 5938. Plaza South 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 PLAZA SOUTH FAILED TO ENSURE THAT A CURRENT FIRE INSPECTION IS AVAILABLE Section 400.441(1)(a)l.m, Florida Statutes and/or Rule 58A-5.015(1) (a)3, Florida Administrative Code (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS ITT VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During a complaint investigation conducted on 5/03/05 and based on observation, interview and record tw review, the facility did not provide proof of a current fire inspection. 8. Facility tour, interview with facility staff, and record review conducted on 05/03/05 at 9:30 AM revealed that facility failed to maintain proof of current fire inspection report, that the report was misplaced and therefore proof of current fire inspection report was unavailable for review and inspection. Correction Date: 06/03/05. 9. During the follow-up conducted on 6/14/05 and based on observation, interview and record review, the facility still did not provide proof of a current fire inspection. 10. Facility tour, interview with facility staff, and record review conducted on 6/14/05 revisit at 9:00 AM revealed that the facility still failed to maintain proof of current fire inspection report and the report was still unavailable for review and inspection. This is an uncorrected deficiency. 11. Based on the foregoing, Plaza South violated Section 400.441(1) (a)1l.m, Florida Statutes, and/or Rule 58A- 5.015(1) (a)3, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Plaza South on Count I. 2. Assess an administrative fine of $500.00 against Plaza South on Count I, for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 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 Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. els E. Rodney, Esq. Assistant General CounSel Agency for Health Care Administration Spokane Building, Suite 103 8350 N. W. 52™ Terrace Miami, Copies furnished to: Diane Lopez, Castillo Field Office Manager Agency for Health Care Administration 8355 NW 53ed Street, 15° Floor Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Florida 33166 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 Ari Schuster, Administrator, The Plaza South, 1690 Collins Avenue, Miami Beach, Florida 33139, and wa to Abraham A. Galbut, Registered Agent of Renaissance Retirement Community, Inc. 999 Washington Avenue, Miami Beach, Florida 33139 on this L day of déghe Soe | 2005. elson E. Rodney SENDER: COMPLETE THIS SECTION A. Signature Sg “CW how gk oes AWC Adldressa 8o that We can return the ca; you, . ! Oa CG bare Of Delivery 0, Is delivery address Gifferent from item'4? Cl Yes YES, enter delivery addresa below: CINo 4 1. Article Addrsssad ta: The GL Kanth 16908 Coenue. "4 ee Beach, FL, B3/BF 2. Articta Number. (Transter tram service PS Form 3811, August 200 PY Servige Type’ er Sertfon Mall © Express Mail | © Registered leturn Receipt for Merchandise Ol inaured Mai’ C.O.D, 14, Restricted Dallvery? (Extra Fea) 7002 2445 0001 4234 pois i Domestic Return Recelpt yoke . vad f ranean

Docket for Case No: 05-003575