FILED STATE OF FLORIDA AHC AGENCY FOR HEALTH CARE ADMINISTRATION: ced =D STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Respondent. SSS MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Petitioner, vs. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Respondent. ; ee 2001 JUN 29 A iy mn JL -3 AM S3 Case NO. 20060082746\()) Oe NO. 06-492911'1(5! DOAH NO. 06-4928 RINGS Case NO. 2006002741 DOAH NO. 06-2387 RENDITION NO.: AHCA-07-O380 -S-OLC Case NO. 2006004503 DOAH NO. 06-2375 Case NO. 2006004629 2006005904 FINAL ORDER Having reviewed the Notice of Intent to Deny dated May 19, 2006, attached hereto and incorporated herein (Ex. 1) and the Administrative Complaints dated June 1, 2006, September 21, 2006 (two complaints), and October 30, 2006, attached hereto and incorporated herein (Exs. 2, 3,4 & 5), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Settlement Agreement (Ex. 6) with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: ORDERED: . 1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. 2. The Respondent shall pay, within thirty (30) days of the date of rendition of this Order, an administrative fine in the amount of $2,500.00 and a survey fee of $484.50. 3. 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: Karen Davis Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 4. Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. 5. Respondent’s petitions for formal administrative proceedings are hereby dismissed. 6. Each party shall bear its own costs and attorney’s fees. 7. The above-styled cases are hereby closed. DONE and ORDERED this 229 day of GAzne— _, 2007, in Tallahassee, Leon County, Florida. Agwunobi, M.D., Secretary Agency foy Health Care Administration 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: John F. Gilroy, III, Esq. Thomas J. Walsh II, Esq. 1435 East Piedmont Dr., Suite 215 Agency for Health Care Admin. Tallahassee, Florida 32308 525 Mirror Lake Drive N., #330G (U. S. Mail) St. Petersburg, Florida 33701 : Interoffice Mail Karen Davis Elizabeth Dudek .| Finance & Accounting Deputy Secretary Agency for Health Care Admin. Agency for Health Care Admin. 2727 Mahan Drive, MS #14 2727 Mahan Drive, Bldg #1, MS #9 Tallahassee, Florida 32308 Tallahassee, Florida 32308 Interoffice Mail) _ (Interoffice Mail) Jan Mills Honorable T. Kent Wethereil, IT Agency for Health Care Admin. Div. of Administrative Hearings 2727 Mahan Drive, Bldg #3, MS #3 The DeSoto Bldg. Tallahassee, Florida 32308 1230 Apalachee Parkway (Interoffice Mail) Tallahassee, Florida 32399-3060 Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the 27 day of Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 45/15/2007 14:13 8584229221 GILROY PA PAGE 82/12 STATS OF FLORIDA AGENCY FOR FEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, DOAH Nos. 06-2387 : 06-4929 vs. Case Nos. 2006008274 : 2006002741 MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Respondent. a 2 MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Petitioner, : DGAH No. 06-2375 ve Case Nos. 2006004503 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, - ‘Respondent. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2006004629 2006005904 MANO INVESTMENTS, INC., d/b/a PALMETTO PLACE ALF, Respondent. SETTLEMENT AGREEMENT The State of Florida, Agency for Health Care Administration (hereinafter the "Agency”), through its undersigned representatives, and Manjo Investments, Inc., d/b/a Palmetto Place ALF, and Amanda N. Mark, individually (hereinafter collectively as “Palmetio"), pursuant to Section EXHIBIT 6 65/15/2887 14:13 8564229221 GILROY PA PAGE 120.57(4), Florida Statutes (2006), each individually, a "party", collectively as "parties,” hereby enter into this Settlement Agreement ("Agreement") and agree as follows: . ; WHEREAS Palmetto is an assisted living facility licensed pursuant to Chapter 429, Part I, Florida Stanates (2006), and Chapter 58A-5, Florida Administrative Code; and WHEREAS the Agency has jurisdiction by virtue of being the regulatory and licensing authority over assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2006); and WHEREAS the Agency served Palmetto with four (4) Administrative Complaints notifying the party ofits intent to revoke its license to operate an assisted living facility, license number 5630, and/or to impose civil penalties of twelve thousand five hundred dollars ($12,500.00), plus survey fees in the sur of four hundred eighty-four dolars fifty cents ($484.50); and WHERAS the Agency served Palmetto with a Notice of Intent to Deny its application for renewal of licensure as above referenced; and WHEREAS Palmetto requested formal administrative hearings for the above styled proceedings; 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 partics have negotiated end 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, including Paimetto’s principal owner in her individual capacity, Amanda N. Mark, intending to be legally bound, agree as follows: i. All recitals are te and correct and are expressly incorporated herein. 83/12 5/15/2087 14:13 8564229227 GILROY PA PAGE 64/12 2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties. 3. Upon fall execution of this Agreement, Palmetto agrees to the withdrawal of the Petitions for Formal Administrative Proceedings; agrees to waive any and all appeals and proceedings to which it may be cntitled including, but not limited to, an informal proceeding under Subsection 120.57(2), Florida Statutes (2006), a formal proceeding under Subsection 120.57(1), Florida Statutes (2006), appeals under Section 120.68, Florida Statutes (2006); and declaratory and all writs of relief in any court or quasi-court (DOAN) of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitied. Provided, however, that no agreement herein, shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement. 4. The patties stipulate and agree: a, That Palmetto shall pay to the Agency, within thirty (30) days of the date of the Final Order adopting this Agreement, administrative fines in the sum of two thousand five hundred dollars ($2,500.00) and survey fees in the sum of four hundred eighty-four dollars and fifty cents ($484.50); b. That forty-five (45) days following the date of the Final Order adopting this Agreement, the license of Palmetto as an assisted living facility, be it active, conditional, provisional, or other status in litigation, and any claim for the renewal of the same, including but not limited to any active, provisional, conditional, or other licensure status in litigation of license number 5630, shail be relinquished to and returned to the Agency, and c. The Palmetto shall, as of 12:01 A.M. on the forty-sixth (46") day following the date of the Final Order adopting this Agreement, have no right, 25/15/2807 14:13 5. 8504220221 GILRCY PA PAGE license, or authority to operate as an assisted living facility or other health care facility regulated by the Agency, and a Palmetto, both in its corporate capacity, and Amanda N. Mark, individually, or any entity in which Palmetto in its corporate capacity or Amanda N. Mark, individually holds an ownership interest, shall not apply for a new license which now, or in the fiture, may be issued by the Agency, seek license renewal, or attempt to acquire an existing license, or operate any health care facility, including, but not limited to, an assisted living facility, or seek licensure, certification, or other approval over which the Agency has been granted , regulatory authority, for a period of four (4) years commencing on the date of the Final Order adopting this Agreement, and ¢. in addition to the fines and survey fees payable pursuant to the provisions of subparagraph (4)(a) above, the sum of ten thousand dollars ($10,000.00) in : administrative fines shall become immediately due and payable from Palmetto to the Agency should Palmetto, in its corporate capacity or Amanda N. Mark, individually, breach the terms of paragraph (4)(d) of this Agreement. The patties stipulate that in the event that the Palmetto, in its corporate capacity or Amanda N. Mark, individuality, or any entity in which Palmetto in its corporate capacity or Amanda N, Marks, individually, holds an interest, file for or otherwise seek licensure within the four (4) calendar years subsequent to the date of the Final Order adopting this Agreement, the application shall be summarily denied and that the Palmetto in its corporate capacity and Amanda N. Matks individually and on behalf of any other entity in which Palmetto or Amanda N. Marks holds an ownership interest, affirmatively waive any right to challenge the denial of licensure by the Agency pursuant to the provisions of this Agreement in any forum, judicial or quasi-judicial, including any rights under the Florida Administrative Procedure Act, Chapter 120, 4 85/12 5/15/2087 14:13 8564228221 GILROY PA PAGE 6/12 Florida Statutes (2006), or to pursue any claim, including, but not limited to, a claim for damages, injunctive relief, attorney’s fees, and costs, in any forum, judicial or quasi-judicial. 6. Venue for any action bronght to enforce, challenge, or otherwise litigate the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Cireuit Court of Leon County, Florida. vA Palmetto neither admits nor denies the allegations raised in the administrative complaints and Notice of Intent referenced herein and the Agency asserts the validity thereof. The Agency agrees that it will not impose any further penalty against Palmetto as a result of the surveys referenced in the charging documents of these canses, however, no agreement made herein shall preclude the Agency from imposing a penalty against Palmetto for any deficiency/violation of statute or rule identified in a future survey of Palmetto, which constitutes a “repeat” or “uncorrected” deficiency from the surveys referenced in the charging documents of these causes. The parties agree that in such a “repeat” or “uncorrected” case, the deficiencies from the surveys referenced in the charging documents of these causes shall be deemed found without further proof. Furthermore, no agreement made herein shall preclude the Agency from using the deficiencies from the surveys referenced in the charging documenis of these causes in any decision regarding licensure of Palmetto as any of the following ALF types: extended congregate care, limited nursing services, or limited mental health. 8. Upon fall execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terns of this Agreement and closing the above-styled cases. 9. Each party shall bear its own costs and attorney fees. 10. This Agreement shall become effective on the date upon which itis fully executed by all the parties. 11. Palmetto, corporately for itself, and Amanda N. Marks, individualty, for herself, and for any related or resulting organizations, ita successors or transferees, attorneys, heirs, and 5 , 85/15/2887 14:13 8584228221 GILROY PA PAGE 97/12 executors or administrators of either, do hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attomeys 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 coutt or administrative forum, including any claims arising out of this Agreement, by or on behalf of Palmetto or related facilities. 12, The undersigned have read and understand this Agreement and have authority to bind their respective principals to'it. 13. This Agreement is intended solely to resolve this litigation between the Agency and Palmetto as the same relates to the Agency’s regulatory responsibilities over Respondent 2s pleaded in the Administrative Complaints at issue. 14. Inthe event that Palmetto was a Medicaid provider at the subject time, this Agreement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues. 15. Palmetto agrees that if any funds to be paid under this agreement to the Agency are not paid within thirty-one (31) days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Palmetto in the Final Order, or any portion thereof, owed by Palmetto to the Agency from any present or future funds owed to Palmetto by the Agency, and that the Agency shall hold a lien against present and future funds owed to Palmetto by the Agency for said amounts until paid. 16. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph eleven (11) of this Agreement. 17, This Agreement contains the entire understandings and agreements of the parties and supersedes eny prior oral or written agreements between the parties. $ 65/15/2007 14:13 8584229221 GILROY PA PAGE 48/12 18, This Agreement may not be amended except in writing. Any attempted assignment of this Agreement by Palmetto or related facilities, its successor or any resulting organization, shall be void. 19, Allparties agree that 4 facsimile signature contained herein shall be as valid and binding as an original signanire. ‘The following representatives hereby ackuowledge that they are duly authorized to enter into this Agreement. Fhizabeth John F, Gilroy, Ti, Esq. Deputy - Counsel for Manjo Investments Inc. Managed Care and Florida Bar.No. 454729 as Health Quality Assurance . 1435 East Piedmont Drive, Suite-4607 Agency for Health Care Administration - Tallahassee, FL. 32308 Flotide Bar No” 0096598 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 DATED: Sf 207 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701 DATED: 7 b,

Docket for Case No: 06-002375