bow 5 STATE OF FLORIDA [6 sy / AGENCY FOR HEALTH CARE ADMINISTRATION PH 4, Diyvi0 ‘ (Sion AGENCY FOR HEALTH CARE ADM ye ON op ADMINISTRATION, HEA aad VE os Petitioner, AHCA No.: 2005009949 v. Return Receipt Requested: 7002 2410 0001 4234 6541 Ole- 94s > ROSA ADULT CARE, INC., d/b/a ROSA ADULT CARE #2, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this Administrative Complaint against Rosa Adult Care, Inc., d/b/a Rosa Adult Care #2 (hereinafter “Rosa Adult Care #2”), 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 of $5,000.00 pursuant to Section 400.419, or revocation of license pursuant to Section 400.414(1)(e), Florida Statutes (2004), for the protection of the public health, safety and welfare and $311.00 survey fee pursuant to Section 400.419(10), and 400.428(3) (c), Fla. Stat. (2004) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Miami-Dade County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative 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. Rosa Adult Care #2 operates a 6-bed assisted living facility located at 43 NW 136% Place, Miami, Florida 33182. Rosa Adult Care #2 is licensed as an assisted living facility license number AL9736, with an expiration date of August 15, 2005. Rosa Adult Care #2 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 ROSA ADULT CARE #2 FAILED TO PASS ANNUAL FIRE INSPECTION Section 400.441(1) (a)1.m, Florida Statutes and/or Rule 58A- 5.015(1) (a)3, Florida Administrative Code (FACILITY RECORDS STANDARDS ) UNCORRECTED CLASS III VIOLATION N 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During a complaint investigation conducted on 5/09/05 and based on observation, interview and record review revealed that the facility failed to pass an annual fire inspection. 8. Observation on 5/9/2005 at 10:00 AM revealed that the facility failed to pass an annual fire inspection on 4/26/2005. The most current satisfactory fire inspection expired 3/29/2005. There was not a fire detector in the garage which has been made into a bedroom for Resident #5. 9, Interview on 5/9/2005 at 12:30 PM with facility administrator revealed that the facility did not pass the annual fire inspection due to the local fire jurisdiction stated that the facility was not in compliance according to the fire code. 10. Record review on 5/9/2005 at 10:15 AM revealed that the facility failed to pass an annual fire inspection conducted by the local fire marshal or authority having jurisdiction. Correction date given: 6/09/05. 11. During the follow-up conducted on 7/26/05 and based at 10:00 AM revealed that the facility still failed to pass an annual fire inspection on 6/15/2005 with a final notice of violation stating that the previous violations were not corrected. 12. Interview on 7/26/2005 at 11:00 AM with facility staff revealed that she was new and did not have access to facility records. 13. Record review on 7/26/2005 at 10:00 AM of the fire report revealed that the facility still failed to pass an annual fire inspection conducted by the local fire marshal or authority having jurisdiction. Uncorrected deficiency from the survey of 5/09/05. 14. Based on the foregoing, Rosa Adult Care #2 violated Section 400.441(1) (a)l.m, Florida Statutes and/or Rule 58A- 5.015(1) (a)3, Florida Administrative Code, an uncorrected ‘Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT II ROSA ADULT CARE #2 FAILED TO PROVIDE DEMOGRAPHIC DATA FOR ALL . RESIDENTS Rule 58A-5.024(3) (a), Florida Administrative Code (RESIDENT RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 15. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review revealed the facility failed to provide demographic data for resident #5. 17. Observation on 5/9/2005 at 12:00 PM revealed that the facility failed to provide demographic data for resident 45. . 18. Interview on 5/9/2005 at 12:30 PM with the facility administrator and she stated that the resident was a new resident and did not have any demographic data during the survey. 19. Record review on 5/9/2005 at 12:00 PM of the resident records revealed that resident #5 was admitted to the facility on 3/2/2005.. The facility failed to provide demographic data for resident #5 beyond 30 days. Correction Date: 6/9/2005. 20. During the follow-up conducted on 7/26/05 and based on observation, interview and record review revealed the facility still failed to provide demographic data for resident #5. 21. Observation on 7/26/2005 at 10:30 AM revealed that the facility still failed to provide demographic data for resident #5. 22. Interview on 7/26/2005 at 10:30 AM with the facility staff stated that she did not administrator and she stated that she did not have access to facility records and that the administrator was the only staff person who had access to facility records. The box that stored the records was locked and the staff on-duty did not have the key. 23. Record review on 7/26/2005 at 10:30 AM of the resident records revealed that resident #5 the facility still failed to provide demographic data for resident #5 beyond 30 days. Uncorrected Deficiency from the 5/09/05 survey. 24, Based on the foregoing, Rosa Adult Care #2 violated Rule 58A-5.024 (3) (a), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this cage, an assessed fine of $500.00, or revocation of licensure. COUNT IIT ROSA ADULT CARE #2 FAILED TO PROVIDE AN ADMITTING WEIGHT RECORD FOR ALL RESIDENTS Rule 58A-5.024(3)(£), Florida Administrative Code (RESIDENT RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review the facility failed to provide an admitting weight record for resident #5. 27. Observation of resident records on 5/9/2005 at 12:00 PM revealed that resident #5 did not have a record of his admitting weight. Resident #5 was admitted to the facility on 3/2/2005. 28. Interview on 5/9/2005 at 12:45 PM with the facility administrator revealed that she did not have information regarding resident #5's weight information. 29. Record review of resident records on 5/9/2005 at 12:00 PM revealed that the facility failed to provide admitting weight record for resident #5. Correction Date: 6/9/2005 30. During the follow-up conducted on 726/05 and based on observation, interview and record review the facility still failed to provide an admitting weight record for resident #5. 31. Observation of resident records on 7/26/2005 at 12:00 PM revealed that resident #5 still did not have a record of his admitting weight. Resident #5 was admitted to the facility on 3/2/2005. 32. Interview on 7/26/2005 at 12:45 PM with the facility staff revealed that she did not have access to that information regarding resident #5's weight information. The box storing that information was locked. 33. Record review of resident records on 7/26/2005 at 12:00 PM revealed that the facility still failed to provide admitting weight record for resident #5. Uncorrected Deficiency from the 5/09/05 survey. 34. Based on the foregoing, Rosa Adult Care #2 violated Rule 58A-5.024(3) (a), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT IV ROSA ADULT CARE #2 FAILED TO ENSURE CURRENT CONTRACT FOR RESIDENTS Sections 400.424(1), and 400.424(5), Florida Statutes and/or Rules 58A-5.024(3) (i), and 58A-5.025(1), Florida Administrative Code (RESIDENT RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 35. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. During the complaint investigation conducted on 5/09/05 the facility failed to ensure that resident #1, resident #2 and resident #5 did not have a current contract with the facility. 37. Observation of the resident records on 5/9/2005 at 12:00 PM revealed that resident #1, resident #2 and resident #5 did not have a contract with the facility. 38. Interview conducted on 5/9/2005 at 12:45 PM with the facility administrator revealed that she was unaware of that the three residents did not have completed contracts with the facility and she would complete them immediately. 39. Review of resident records on 5/9/2005 at 12:00 PM revealed that the facility failed to provide contracts for resident #1, resident #2 and resident #5. Correction Date: 6/9/2005. 40. During the follow-up conducted on 7/26/05 and based on observation, interview and record review the facility still failed to provide resident contracts for resident #1, resident #2 and resident #3. 41. Observation of the resident records on 7/26/2005 at 12:00 PM revealed that resident #1, resident #2 and resident #5 still did not have a contract with the facility. 42. Interview conducted on 7/26/2005 at 12:45 PM with the facility staff stated that she did not have access to the facility records and that the facility administrator was the only staff that had access to the records revealed that she was unaware of that the three residents did not have completed contracts with the facility and she would complete them immediately. 43. Review of resident records on 7/26/2005 at 12:00 PM revealed that the facility still failed to provide contracts for resident #1, resident #2 and resident #5. Uncorrected deficiency from the survey of 5/09/05. 44. Based on the foregoing, Rosa Adult Care #2 violated Sections 400.424(1), and 400.424(5), Florida Statutes, and/or Rules 58A-5.024(3) (i), and S58A-5.025(1), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT V ROSA ADULT CARE #2 FAILED TO PROVIDE HEALTH ASSESSMENT FOR RESIDENTS Rule 58A-5.0181(2) (a), Florida Administrative Code (ADMISSIONS CRITERIA STANDARDS) UNCORRECTED CLASS III VIOLATION 45. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 46. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review revealed that resident #5 did not have a health assessment. '47. Observation on 5/9/2005 at 12:10 PM revealed that the facility failed to provide a health assessment for resident #5. 48. Interview with facility administrator on 5/9/2005 at 12:45 PM revealed that resident #5 is a new resident and that he does not. have a health assessment. Correction date: 6/9/2005 49. During the follow-up conducted on 7/26/05 and based on observation, interview and record review revealed that resident #5 still did not have a health assessment. 50. Observation on 7/26/2005 at 11:00 AM revealed that the facility still failed to provide a health assessment for resident #5. 51. Interview with facility staff on 7/26/2005 at 11:10 AM revealed that she was unaware and did not have access to the facility records. 52. Record review on 7/26/2005 at 11:00 AM revealed that the facility still failed to provide a health assessment for resident #5. Uncorrected deficiency from the 5/09/05 survey. 53. Based on the foregoing, Rosa Adult Care #2 violated Rule 58A-5.0181(2) (a), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT VI ROSA ADULT CARE #2 FAILED TO PROVIDE BACKGROUND SCREENING FOR STAFF Section 400.417(2), Florida Statutes, and/or Rule 58A- 5.019(3), Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 54. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. During the complaint investigation conducted on 5/09/05 and based on interview and record review, the facility failed to ensure that direct care staff had undergone. required background screening. 56. Observation of personnel records on 5/9/2005 at 1:00 PM revealed that the facility failed to provide level 1 background screening for staff #1 and staff #2. Per staff #2 file there was no copy of identification of any sort provided. 57. Interview on 5/9/2005 at 1:30 PM with the facility administrator revealed that she was unaware that the personnel did not have FDLE level 1 background screening. 11 98. Record review of personnel records on 5/9/2005 at 1:00 PM revealed that staff #1 and staff #2 did not have FDLE Level 1 background screening. Correction Date Given: 6/9/2005. 59. During the follow-up conducted on 7/26/05 and based on interview and record review, the facility still failed to ensure that direct care staff had undergone required background screening. 60. Observation of personnel records on 7/26/2005 at 11:00 AM revealed that the facility still failed to provide level 1 background screening for staff #1 and staff #2. Per staff #2 file there was no copy of identification of any sort provided. 61. Interview on 7/26/2005 at 11:00 AM with the facility staff revealed that she had no access to the facility records and was unaware that the personnel still did not have FDLE level 1 background screening. 62. Review of personnel records on 7/26/2005 at 11:00 AM revealed that staff #1 and staff #2 still did not have FDLE level 1 background screening. Uncorrected deficiency from the 5/09/05 survey. 63. Based on the foregoing, Rosa Adult Care #2 violated Section 400.4174(2), Florida Statutes, and/or Rule 58A- 5.019(3), Florida Administrative Code, an uncorrected Class TIL deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT VII ROSA ADULT CARE #2 FAILED TO PROVIDE CPR TRAINIG FOR ALL, STAFF Rule 58A-5.019(4) (a)4, Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 64. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 65. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review the facility failed to provide CPR training for the administrator, staff #1 and staff #2. 66. Observation on 5/9/2005 at 1:00 PM of personnel records revealed that the administrator, staff #1 and staff #2 did not have the required CPR training. 67. Interview with the facility administrator on 5/9/2005 at 1:30 PM revealed that she was unaware that the CPR training was required. She assumed that the First Aid training satisfied the CPR training. The surveyor informed the administrator that it is required that at least on staff member who is trained in First Aid and CPR must be within the facility at all times when residents are in the facility. She understood and stated that she would schedule the training immediately. 68. Record review of personnel records on 5/9/2005 at 1:00 PM revealed that the administrator, staff #1 and staff #2 13 did not have the required CPR training. Correction Date Given: 6/9/2005 69. During the follow-up conducted on 7/26/05 and based on observation, interview and record review the facility still failed to provide CPR training for the administrator, staff #1 and staff #2. 70. Observation on 7/26/2005 at 11:00 AM of personnel records revealed that the administrator, staff #1 and staff #2 did not have the required CPR training. 71. Interview with the facility staff on 7/26/2005 at 11:30 AM revealed that she did not have access to facility records and was unaware of the status of the CPR training. 72. Record review of personnel records on 7/26/2005 at 11:00 AM revealed that the administrator, staff #1 and staff #2 still did not have the required CPR training. Uncorrected deficiency from the 5/09/05 survey. 73. Based on the foregoing, Rosa Adult Care #2 violated Rule 58A-5.019 (4) (a)4, Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT VIII ROSA ADULT CARE #2 FAILED TO HAVE AT LEAST ONE STAFF PERSON WHO HAS ACCESS TO FACILITY RECORDS IN CASE OF EMERGENCY ON DUTY AT ALL TIMES : Rule 58A-5.019(4) (a)2, Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 14 74. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 75. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review the facility failed to have at least one staff member who has access to facility and resident records in case of an emergency shall be within the facility at all time when residents are in the facility. 76. Observation on 5/9/2005 at 10:00 AM revealed that upon arrival to the facility staff #2 was the only staff on site. She did not have access to facility and resident records and was unaware of the administrative operations of the facility. Staff #2 had full access to the kitchen and resident rooms. 77. ‘Interview with the facility administrator on 5/9/2005 at 11:00 AM revealed that the staff person was a new hire and was unfamiliar with the facility operations. The facility administrator referred to staff #2 using a name completely opposite to the name the residents referred to or the name that staff #2 gave the surveyor conducting the survey. When asked to provide any type of photo identification staff #2 did not have a driver's license, identification card, passport, etc. 78. Record review of personnel records on 5/9/2005 at 1:00 PM revealed that there was no documentation indicating staff #2 was the person who certificates/trainings were found in the personnel file. No records including an employment application, social security card or identification card was found. The residents referred to, staff #2 in a name different from the certificates found in the file. Correction Date Given: 6/9/2005. 79. During the follow-up conducted on 7/26/05 and based’ on observation, interview and record review the facility still failed to have at least one staff member who has access to facility and resident records in case of an emergency shall be within the facility at all times when residents are in the facility. 80. Observation on 7/26/2005 at 10:00 AM revealed that upon arrival to the facility staff #3 was the only staff on site. She still did not have access to facility and resident records and was unaware of the administrative operations of the facility. Staff #2 had full access to the kitchen and resident rooms. 81. Interview with the facility staff #30n 7/26/2005 at 11:00 AM revealed that the staff person was still a new hire “and was unfamiliar with the facility operations. The facility staff #3 stated that she started two days ago and was unfamiliar with the facility. When asked to provide any type of photo identification staff #3 still did not have a driver's license, identification card, passport, etc. 16 82. Record review of personnel records on 7/26/2005 at 10:00 AM revealed that there was no documentation indicating staff #3 was the person who certificates/trainings were found in the personnel file. No records were available that included an employment application, social security card or identification card was found. Uncorrected deficiency from the 5/09/05 survey. 83. Based on the foregoing, Rosa Adult Care #2 violated Rule 58A-5.019(4) (a)2, Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT IX “ROSA ADULT CARE #2 FAILED TO PROVIDE CURRENT EMERGENCY MANAGEMENT PLAN Section 400. 441(1) (b), Florida Statutes, and/or Rule 58A-5. 026(2), Florida Administrative Code (EMERGENCY MANAGEMENT) UNCORRECTED CLASS IIIT VIOLATION 84. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 85. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review, the facility failed to provide proof of a current Emergency Management Plan. 86. Observation on 5/9/2005 at 12:00 PM revealed that the facility failed to maintain proof of current Emergency Management Plan. 87. Interview with facility administrator on 5/9/2005 at 12:30 PM revealed that she has been trying to contact her representative with the Miami-Dade Emergency Management to have he plan approved. She stated that she sent the plan but did not provide proof. 88. Record review on 5/9/2005 at 12:00 PM revealed of facility records revealed that the facility failed to provide proof of a current Emergency Management Plan. Correction Date Given: 6/9/2005. 89. During the follow-up conducted on 7/26/05 and based on observation, interview and record review, the facility still failed to provide proof of a current Emergency Management Plan. 90. Observation on 7/26/2005 at 10:00 AM revealed that the facility still failed to maintain proof of current Emergency Management Plan. 91. Interview with facility staff on 7/26/2005 at 10:00 AM revealed that she did not have access to facility records and was unaware of the status of the plan. 92. Record review on 7/26/2005 at 10:00 AM of facility records revealed that the facility still failed to provide proof of a current Emergency Management Plan. Uncorrected deficiency from the 5/09/05 survey. 93. Based on the foregoing, Rosa Adult Care #2 violated Section 400.441(1)(b), Florida Statutes, and/or Rule 58A- 18 5.026(2),° Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. COUNT X ROSA ADULT CARE #2 FAILED TO ENSURE THAT THE STAFF WAS FREE FROM A COMMUNICABLE DISEASE Section 400.4275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code (STAFF RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 94. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 95. During the complaint investigation conducted on 5/09/05 and based on observation, interview and record review the facility failed to ensure that the administrator, staff #1 and staff #2 had proof verifying freedom from a communicable disease statement. 96. Observation of personnel records on 5/9/2005 at 1:00 PM revealed that the facility failed to proof freedom from a communicable disease statement for the administrator, staff #1 and staff #2. 97. Interview with the facility administrator on 5/9/2005 at 1:30 PM revealed that she was aware that the staff lacked a communicable disease statement and would contact the physician to schedule appointments. 98. Record review of the personnel records on 5/9/2005 at 1:00 PM revealed that the facility failed to provide 19 communicable disease statements for the administrator, staff #1 and staff #2. Correction Date Given: 6/9/2005. 99. During the follow-up conducted on 7/26/05 and based on observation, interview and record review the facility still failed to ensure that the administrator, staff #1 and staff #2 had proof verifying freedom from a communicable disease statement. 100. Observation of personnel records on 7/26/2005 at 11:00 AM revealed that the facility still failed to proof freedom from a communicable disease statement for the administrator, staff #1 and staff #2. 101. Interview with the facility staff on 7/26/2005 at 11:30 AM revealed that she did not have access to the facility records and was aware that the staff still lacked a communicable disease statement. 102. Record review of the personnel records on 7/26/2005 at 11:00 AM revealed that the facility still failed to provide communicable disease statements for the administrator, staff #1 and staff #2. Uncorrected deficiency from the 5/09/05 survey. 103. Based on the foregoing, Rosa Adult Care #2 violated Section 400.4275(4), Florida Statutes, and/or Rule 58a- 5.024(2) (a), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00, or revocation of licensure. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA May assesS a survey fee of $311.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through xX. B. Revoke the license of Rosa Adult Care #2 on Counts I through X pursuant to Section 400.414(1) (e), Florida Statutes. Cc. In the alternative to paragraph B, assess an administrative fine of $10,000.00 against Rosa Adult Care #2 on Counts I through X violations pursuant to Section 400.419, Florida Statutes. 21 D. Assess a survey fee of $311.00 against Rosa Adult Care #2, pursuant to Sections 400.419(10), and 400.428(3) (c), Florida Statutes. E. 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 for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 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. ‘Nellgon E. fRodney Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52"? Terrace Suite 103 Miami, Florida 33166 nN tN Copies furnished to: Field Office Manager Agency for Health Care Administration 8355 NW 53™¢ Street, 15° Floor Miami, Florida 33166 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Ana Escalona, Rosa Adult Care #2, 43 NW 136" Place, Miami, Florida 33182o0n Veen bie, 23, 2005. de E. es

Docket for Case No: 06-002453