STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR. HEALTH CARE ADMINISTRATION, Petitioner, ZZ:4 Hd 81 das 90 vs. Case No. 2006007424 MYRNA LEGGIO, f) lo - 4 S | oy Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against, MYRNA LEGGIO, (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an adult family care home pursuant to § 429.69(2) and (5), Fla. Stat. (2006) and to impose an administrative fine in the sum of two thousand dollars ($2,000.00) based upon two cited State Class I deficiencies pursuant to § 429.71(1)a), Fla. Stat, (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, 429.69, 429.71, and 429.73, Fla. Stat. (2006). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of adult family care homes and enforcement of all applicable federal regulations, state statutes and rules governing adult family care homes pursuant to the Chapter 429, Part II, Florida Statutes, and Chapter 58A- 14 Florida Administrative Code, respectively. 4. Respondent operates a five (5) bed adult family care home located at 3330 Irondale Avenue, Spring Hill, Florida 34609, and is licensed as an adult family care home, license number 6905222, 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. That pursuant to Florida law: “(1) A resident of an adult family-care home may not be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the State ’ Constitution, or the Constitution of the United States solely by reason of status as a resident of the home. Each resident has the right to, inter alia, live in a safe and decent living environment, free from abuse and neglect and be treated with consideration and respect and with due recognition of personal dignity, individuality, and privacy... exercise civil and religious liberties, including the right to independent personal decision... and to be free from chemical and physical restraints” §429.628(1) Fla. Stat. (2005). “Physical restraint” means a device or item which physically limits, restricts, or deprives an individual of movement or mobility. The term also includes any device which was not specifically manufactured as a restraint but has been altered, arranged or otherwise used for this purpose or otherwise been modified to be used as a physical restraint. The term does not include an item or device which the individual can remove or avoid without assistance. R. 58A- 14.0002(15), Fla. Admin. Code. “Admission. In Order to be admitted as a resident to an AFCH an individual must... Not be bedridden [and] not require the use of physical restraints.” R. 58A-14.0061(1)(h) and (j), Fla. Admin. Code. 8. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 9. That based upon observation and interviews, the Respondent facility failed to ensure a safe and decent living environment for its residents as the Respondent facility utilized restraints of several types which would limit the ability of residents to exit the Respondent facility in the case of emergency, exercise civil and religious liberties, including the right to independent personal decisions and deprived residents of their personal dignity. Failure to provide restraint free surroundings has the potential for the inability of residents to safely exit the home in case of emergency, be said emergency of a personal health or safety issue or a facility wide safety concern such as fire or other disaster. 10.‘ That at 8:30 AM on August 11, 2006, representatives of Spring Hill Fire Rescue conducted an unannounced annual fire inspection of the Respondent facility. Inclusive of the findings thereof are the following: a. That all but one resident was still in their beds; b. That the doors to front bedroom and a bedroom adjacent thereto near the front were locked; That the locks to these two bedrooms were installed such that the locking mechanism, ad thus the ability to lock and unlock the doors, could only be controlled from outside the individual rooms; That the fire personnel unlocked and entered the first bedroom to discover a resident; That egress from the bedroom from a window was blocked by shrubs, plants, and a grill; That a second locked-from-the-outside bedroom contained two residents in hospital beds with side railings in the up position; That a wheelchair was situated at the foot of and in between the two beds; That routes of egress other than the locked-from-the-outside door were a door to a contiguous room or a window; That the route from the bed to the windows was approximately twenty-four inches wide; That a wheelchair could not traverse the narrow route; That the window egress was blocked on the outside by assorted articles piled on and about the outside of the structure; Egress to the contiguous room and through to the pool area was blocked by items including boxes, piles of clothing, toys, two beds, and a bedroll between the beds; A third room contained a resident in a hospital bed with side rails up; The room had previously been designated as limited for use by persons capable for prompt evacuation as the window was too high for egress absent a climb; 0. That the resident in the room suffered from multiple sclerosis and could not exit the room in an emergency situation; p. That the above, amongst other issues, were cited by Spring Hill Fire Safety as violations. 11. That the Petitioner’s representative toured the Respondent’s facility in the afternoon of August 11, 2006 with Respondent’s staff member number one (1) and noted the following: a. That bedroom number three (3) contained two (2) hospital beds with attached full bed rails; b. That one of the beds had the bed rails in the down position; c. That the other bed had one of the full bed rails in the up position; d. That a collapsed wheelchair sat at the foot of the second bed; e. That the doors to bedrooms numbered one (1) and three (3) contained locks which operated from the outside of the door; f. That bedroom number one (1) contained a bedside toilet. 12. That the Petitioner’s representative interviewed Respondent’s staff member number one (1) on August 11, 2006 who indicated as follows: a. That the staff member was unaware of the reason the hospital beds had bed rails; db. That the outside door lock on bedroom number one (1) was "[P]robably to keep [resident number three (3)] from wandering around at night;" c. That the staff member was unaware of a reason for an outside lock on bedroom number three (3). 13. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated the following: a. That the bed rails were on the beds as “...that is the way the beds came;” b. That the bed rails are used by the provides to prevent residents from falling out of bed; c. That the outside bedroom locks had been placed on the outside because one of the residents kept accidentally locking themselves in the bedrooms; d. That resident number three (3) had the tendency to wander into other areas of the home at night; e. That regarding the bedside toilet present in bedroom number one (1), that it is easier for the residents to use the bedside toilet at night than go to the bathroom. 14. That the Petitioner’s representative interviewed resident number three (3), a resident of bedroom number one (1) who indicated that the resident utilized the bedside toilet at night as the bedroom door is locked and the resident is unable to get to the hall bathroom. 15. That the same represents the Respondent facility’s actions and inactions, through the use of restraints designed as such, and through the use of other items such as locks, wheelchairs, and debris, to create an environment endangering resident safety by limiting resident egress from rooms. Such actions rob the resident’s of personal dignity, requiring continent adults to utilize an in room portable commode, virtually imprisoning residents of a facility meant to be residing in a family-like setting, and denying the resident’s their right to exercise their individual and civil liberties, including the rights to freely travel within the common areas of the facility. 16. That said actions reflect a pattern of intentional conduct including, but not limited to, the provision of a portable commode in a resident’s room where the resident would be locked in the room overnight, the installation of locks on bedroom doors such that inhabitants of the rooms would be and could be locked in the room’s interior and unable to effect their own egress, the placement of bed rails in the up position for residents, the use of which has not been prescribed or otherwise authorized. 17. That these actions reflect a callous disregard to the provisions of law and the well-being of residents. 18. That the lack of egress presents an imminent threat to residents to both the occurrence of a emergency situation affecting the facility as a whole and personal emergencies which may arise including but not limited to a resident’s need for medical attention. 19. These intentional or negligent acts materially affect the health, safety, or welfare of residents and directly threaten the physical or emotional health, safety, or welfare of the residents. 20. That the Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the care of residents which presents an imminent danger to residents or guests or a substantial probability that death or serious physical or emotional harm would result therefrom and cited Respondent for a State Class I deficiency. 21. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 22. That the same constitutes a Class I offense as defined in Florida Statute 429.71(1)(a). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an adult family care home in the State of Florida, pursuant to § 429.71(1)(a), Fla. Stat. (2006). COUNT IL 23. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 24. ‘That pursuant to Florida law, in order to be admitted to an AFCH an individual must be able to perform, with supervision or assistance, activities of daily living. R. 58A-14.0061(1)(d), Fla. Admin. Code. 25. That pursuant to Florida law, “Assistance with activities of daily living” means individual assistance with...amb[ula]tion — providing physical support to enable the resident to move about and maintain balance and providing necessary assistance with walking, stair climbing, or pushing a wheelchair.” R. 58A-14.002(4)(a), Fla. Admin. Code. 26, That pursuant to Florida law, in order to be admitted as a resident to an AFCH an individual must be capable of self-preservation in an emergency situation involving the immediate evacuation of the AFCH, with assistance with ambulation if needed. R. 58A- 14.0061(1)(c) Fla. Admin. Code. 27. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 28. That based upon observation and interview, the Respondent facility admitted two (2) of five (5) residents who were inappropriate for the Respondent facility as they were unable to perform with assistance, activities of daily living (ADLs). Inappropriate admission of a resident to an Adult Family Care Home presents an imminent danger to residents and a substantial probability that death or serious physical or emotional harm would result therefrom due to inappropriate care and services and decline in physical well being. 29, That the Petitioner’s representative interviewed Respondent’s staff member number one (1) on August 11, 2006 who indicated that residents numbered four (4) and five (5) were not able to participate in their daily care and had to be lifted in and out of bed. 30. That the Petitioner’s representative observed residents numbered four (4) and five (5) on August 11, 2006 and noted the following: a. That the residents were transferring to a vehicle to be transferred to another facility; b. That neither resident was able to bear weight or pivot to enter the vehicle; c. That the resident’s had to be lifted by two persons, including the provider and the L.P.N. (Licensed Practical Nurse) who had arrived at the facility to assess the residents for admission in to a skilled nursing facility. 31. That the inability of the resident’s to ambulate and conduct other activities of daily living presents an imminent threat to residents as sufficient and qualified staff are not available to assist on a daily basis and during an emergency that may arise. 32. That resident number five (5) was admitted to the Respondent facility without a health assessment or the knowledge of medication orders and their contents. 33. That allegations that resident number five (5) was admitted for a brief respite period do not mitigate and in fact aggravate the severity of such violations as an unknown and unfamiliar resident, and the attendant unknown health needs of the resident, illustrate a disregard by the Respondent to meet the minimum quality of care requirements placed on the Respondent by law. 34, These intentional or negligent acts of admitting and maintaining these resident’s at the facility materially affect the health, safety, or welfare of residents and directly threaten the physical or emotional health, safety, or welfare of the residents. 35. That the Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the care of residents which presents an imminent danger to residents or guests or a substantial probability that death or serious physical or emotional harm would result therefrom and cited Respondent for a State Class I deficiency. 36. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 37. That the same constitutes a Class I offense as defined in Florida Statute 429.71(1)(a). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand ($1,000.00) against Respondent, an adult family care home in the State of Florida, pursuant to § 429.71(1)(a), Fla. Stat. (2006). COUNT Ul 38. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and the remaining counts of this complaint as if fully set forth herein. 39. That the Agency may revoke any license issued under Part I of Chapter 429 of the Florida Statutes for an intentional or negligent act materially affecting the health, safety, or welfare of the adult family care home residents and or the a violation of Part II of Chapter 429, Florida Statutes or adopted rules of Chapter 58A-14, Florida Administrative Code, which results in a condition or practice that directly threaten the physical or emotional health, safety, or welfare of residents. Section 429.69, Fla. Stat. (2006). 40. That the Respondent has been cited with two (2) State Class I deficiencies and five (5) class II deficiencies on an Agency complaint survey of August 11, 2006. 41. That each of these violations constitutes either an intentional or negligent act that materially affects the health, safety, or welfare of the adult family care home residents or is a violation of Part II of Chapter 429, Florida Statutes or adopted rules of Chapter 58A-14, Florida Administrative Code, which results in a condition or practice that directly threaten the physical or emotional health, safety, or welfare of residents, thereby meriting the revocation of the 10 Respondents licensure. 42. The Agency re-alleges and incorporates paragraphs six (6) through thirty-seven (37) of this complaint as if fully set forth herein. 43. That pursuant to Florida law, prior to admission to an AFCH, the individual must be examined by a health care provider using the Resident Health Assessment... R. 58A-14.0061(2), Fla. Admin. Code. 44, That pursuant to Florida law, an AFCH provider shall ensure that each resident on the premises shall have a Resident Health Assessment, DOEA Form 1110, required by Rule 58A- 14.0061, Fla. Admin. Code. A completed and signed form faxed by the health care provider shall be acceptable. Fl. Admin. Code R. 58A-14.0085(1)(a)(1) Fla. Admin. Code. 45. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 46. That based upon the review of records and interview, the Respondent facility failed to attain medical health assessments (DOEA Form 1110) for two (2) of five (5) residents. Failure to procure pertinent health information on residents has the potential for inappropriate care and services to residents. 47. That the Petitioner’s representative reviewed Respondent’s records regarding resident number three (3) on August 11, 2006 and noted a blank health assessment form. 48. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number five (5) on August 11, 2006 and noted that the record contained no evidence of a health assessment, medication list, allergy list, dietary information, physical ability assessment by the Provider, or any other pertinent medical information from a physician. 49. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated the following: a. That the provider was not aware of the missing health assessment for resident number three (3); b. That there was no health assessment or other information for resident number five (5) with the exception of family contact telephone information because the resident was a respite resident who would be residing in the home for six (6) days. 50. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 51. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 52. That the same constitutes a Class II offense as defined in Florida Statute 429.71(1)(b). 53. That pursuant to Florida law, an adult family care home shall maintain a separate record for each resident on the premises for inspection by the agency which shall contain, at a minimum, for residents who self-administer, with or without supervision or assistance, a list of the resident’s current medications; or for residents receiving administration, the record of medications administered as required under Rule 58A-14.007, F.A.C. R. 58A-14.0085(1)(a)(6), Fla. Admin. Code. 54. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 55. That based upon the review of records, observation, and interview, the Respondent facility failed to maintain accurate medication lists for four (4) of five (5) residents. Failure to ensure accurate medication records has the potential for medication errors and related adverse reactions. 56. That the Petitioner’s representative reviewed the medications of and mediation records for resident number one (1) on August 11, 2006 and noted the following: a. That a bottle of medication labeled "Alprazolam 0.25 milligram (mg.), take 1 tablet by mouth twice daily" was maintained; b. That the medication list for the resident read "Alprazolam 0.25 mg., take 1/2 tablet twice daily;" c. That a medication order existed for Vitamin E 400 IU, 1 tablet daily; d. That no Vitamin E medication was maintained; e. That a medication order existed for Aspirin 81 mg. take 1 tablet by mouth daily; f. That a bottle of Aspirin 325 mg., that had been out of date since May 2005, was maintained; g. That a medication order existed for Xalatan Eye Drops 0.005% to be used 3 drops in both eyes at bedtime; h. That the medication list read Xalatan eye drops 0.005%, 1 drop to each eye at bedtime. 57. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated that the provider thought the order for Alprazolam had been changed, that the facility was now using "fish oil" instead of Vitamin E tablets, and that the provider was unaware of the order discrepancy with the resident's eye drops. 58. That the Petitioner’s representative reviewed the medications of and mediation records for resident number three (3) on August 11, 2006 and noted a medication order for Advair 13 Inhaler, use 1 puff twice daily, yet no medication list was maintained in the resident's file. 59. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated awareness that there was no medication list for the resident. 60. That That the Petitioner’s representative reviewed the medications of and mediation records for resident number four (4) on August 11, 2006 and noted the following: a. That a medication order existed for Synthroid 75 micrograms (mcgs.), take 1 tablet daily; b. That the medication list read Synthroid 75 mcgs. with no reference as to how many times a day the medication was to be given. 61. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated the provider had forgotten to document how many times a day the medication was to be given. 62. That the Petitioner’s representative reviewed the medications of and mediation records for resident number five (5) on August 11, 2006 and noted that there was no medication orders and no medication list, yet a filled medication box was located for the resident. 63. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated an unawareness of either what medications were in the medication box or what medications the resident was taking. 64, That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 65. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 14 66. That the same constitutes a Class II offense as defined in Florida Statute 429.71(1)(b). 67. That pursuant to Florida law, an AFCH provider, all staff, each relief person, and all adult household members must meet the Level 1 background screening requirements, or have been exempted from disqualification. Fl. Admin. Code R. 58A-14.008(1)(b). See, Section 429.67(4), Fla. Stat. (2006). 68. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 69. That based upon the review of records and interview, the Respondent facility failed to ensure that staff member number one (1) had a Level I background screening on file. Failure to ensure employees caring for residents have had a Level I background clearance puts the residents at risk for abuse and neglect. 70. That the Petitioner’s representative reviewed the Respondent’s employee file for staff memiber number one (1) and noted no evidence of a Level I background screening. 71. That the Petitioner’s representative interviewed staff member number one (1) on August 11, 2006 who indicated employment by Respondent since April 2006. 72. ‘That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated that a request for a Level I screening with the application had been submitted to the Agency on August 8, 2006 and that staff member number one (1) had been working at the facility as needed since April 2006 and is currently working approximately three (3) days weekly. 73. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 74. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 75. That the same constitutes a Class II offense as defined in Florida Statute 429.71(1)(b). 76. That pursuant to Florida law, the adult family care home provider shall ensure the assistance with or supervision of the self-administration of medication or medication administration. R. 58A-14.007(1)(a) Fla. Admin. Code R. 77. ‘That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. 78. That based upon observation, the review of records and interview, the Respondent provider failed to ensure the provision of assistance with or supervision for one (1) of five (5) resident's medications. Failure to ensure that residents receive the assistance required places the resident at risk for an over dose or missing dosages of their medications. 79. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number five (5) on August 11, 2006 and located no medication orders and no medication list. 80. That the Petitioner’s representative observed on August 11, 2006 a filled medication box for resident number five (5). 81. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated an unawareness of either what medications were in the medication box, or what medications the resident was taking. 82. That the Petitioner’s representative observed on August 11, 2006 the removal of this resident as the resident was identified as needing a higher level of care (skilled nursing facility). 83. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited 16 Respondent for a State Class I deficiency. 84. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 85. That the same constitutes a Class II offense as defined in Florida Statute 429.71(1)(b). 86. That pursuant to Florida law, prescription medications that are centrally stored by an AFCH provider shall be appropriately stored in their legally dispensed, labeled, original containers. R. 58A-14.007(1)(b)(6), Fla. Admin. Code. 87. That on August 11, 2006, the Agency completed a complaint survey of the Respondent facility. . 88. That based upon observation, the review of records, and interview, the Respondent facility failed to ensure they kept one (1) of five (5) resident's medication stored in the legally dispensed, labeled, original containers. Failure to store medications in their properly, labeled containers has the potential for medication errors. 89. That the Petitioner’s representative reviewed the Respondent’s records and medications for resident number one (1) on August 11, 2006 and noted the following: a. That a medication order existed for Lipitor 10 mg. 1 tablet by mouth daily; b. That the resident’s medications included a clear container, which appeared to resemble a camera film container, with handwriting on the plastic container containing 6 white tablets, stating “Lipitor 10 mg.” 90. That the Petitioner’s representative interviewed the Respondent provider on August 11, 2006 who indicated that the provider had placed the tablets in this container. 91. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited 17 Respondent for a State Class II deficiency. 92. That the Agency provided Respondent with a mandatory correction date of September 11, 2006. 93. That the same constitutes a Class II offense as defined in Florida Statute 429.71(1)(b). WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to § 429.69, Fla. Stat. (2006). Respectfully submitted this Zt day of August, 2006. ‘ Thgmas % Walsh IL sel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida 32308. Telephone (850) 922-5873 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. CERTIFICATE OF SERVICE IHEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7004 2510 0005 4049 1673 on August ‘2% 1, 2006 to: Myrna Leggio, Owner/Administrator, 3330 Irondale Avenue, Spring Hill, Florida 34609. Tho alsh If Esquire Copies furnished to: Myra Leggio Owner/Administrator 3330 Irondale Avenue Spring Hill, FL 34609 (U.S. Certified Mail) Thomas J. Walsh, II Agency for Health Care Admin. $25 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) COMPLETE THIS S| ~ B, Recalved by ied rt ), eer WN ft G10 Ls = i D, Is delivery wince different from item 1? C1 Yes i OULNM e. df YES, enter delivery address below: ONo d Maa Neg 10, Adan dtrajor 24330 tre 2. wus SPrno, av \ i. ads SENDER: COMPLETE THIS SECTION ™ Complete Items...2, and 3. Also complete A x OE item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse so that we can return the card to you. ™@ Attach this card to the back of the mailplece, or on the front if space permits. 1, Article Addressed aw Sern — , He Certified Mail S-express 1 C Registered C1 Retum Receipt for Merchandise Ci Insured Mall 1 .0,D. 4, Restricted Dellvary? (Extra Fee) Yes 2. Article Numb ; ‘, raconumee __ 7004 2540 OOS 4049 wk7a_ AMbbOD TAG | PS Form 3811, February 2004 Domestic Return Receipt 102505-02-M-1840 "

Docket for Case No: 06-003519