STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 40M $e HUSEN 0, SU AGENCY FOR HEALTH CARE ZY le ARyar, ADMINISTRATION, 7 - 1 Og Ve Petitioner, , AHCA No.: 2007006067 Vv. Return Receipt Requested: 7002 2410 0001 4235 6960 PALM BEACH COUNTY PUBLIC 7002 2410 0001 4235 6977 BUILDING CORPORATION, INC d/b/a NORTH COUNTY ADULT DAY CARE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this. administrative complaint against. Palm Beach County Public Building Corporation, Inc. d/b/a North County Adult Day Care (hereinafter “North County Adult Day Care”), pursuant to Chapter 429, Part III, and Section 120.60, Florida Statutes, (2006), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $2,000.00 pursuant to Sections 429.911 and 429.913, 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 Palm Beach 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 adult day care centers pursuant to Chapter 429, Part III, Florida Statutes (2006), and Chapter 58A-6, Florida Administrative Code. 5. North County Adult Day Care operates a 15 capacity adult day care center located at 5217 Northlake Boulevard, Palm Beach Gardens, Florida 33418. North County Adult Day Care is licensed as an adult day care center facility under license number 344 with an expiration date of 8/14/07. North County Adult Day Care 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 NORTH COUNTY ADULT DAY CARE DID NOT HAVE A CURRENT FOOD SERVICE INSPECTION REPORT ISSUED BY THE COUNTY Section 429.929(1)(c), Florida Statutes (2006), and/or Rule 58A-6.009(2) (e-£), Florida Administrative Code (CENTER RECORD STANDARD) MINOR VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the re-licensure survey. conducted on 4/04/07 and based upon record review and interview with the Program Nurse on the day of the survey, it was revealed that. the center did not have a current food service inspection report issued by the Department of Health. 8. The center did not have a current food service inspection report issued by the county Department of Health. The Program Nurse was interviewed and after investigation, confirmed the findings. 9. Based on the foregoing, North County Adult Day Care violated Section 429.929(1)(c), Florida Statutes, and/or Rule 58A-6.009(2) (e-f), Florida Administrative Code, which warrants an assessed fine of $500.00. COUNT II NORTH COUNTY ADULT DAY CARE DID NOT OBTAIN A HEALTH STATEMENT WITHIN FORTY FIVE DAYS PRIOR TO THE ADMISSION FOR EACH PARTICIPANT Rule 58A-6.006(1)(a)1, Florida Administrative Code (ADMISSION CRITERIA STANDARDS) MINOR VIOLATION 10. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. During the re-licensure survey conducted on 4/04/07 and based upon record review and interview with the Program Nurse on the day of the survey, it was revealed that the center did not obtain a health statement within forty five days prior to the admission for each participant in two out of the five participant records sampled. 12. Two of five participant records reviewed revealed the health statement for participant #’s 1 and 2 were not obtained within 45 days prior to their admission to the center. Participant #1 was admitted to the center on 7/19/04. His/her health statement was dated 8/19/04. Participant #2 was admitted to the center on 02/13/06, his/her health statement was not dated or signed by a health care provider. The Program Nurse was interviewed and after investigation, confirmed the findings. 13. Based on the foregoing, North County Adult Day Care violated Rule 58A-6.006(1) (a), Florida Administrative Code, which warrants an assessed fine of $500.00. COUNT III NORTH COUNTY ADULT DAY CARE FAILED TO HAVE A STATEMENT FROM A LICENSED HEALTH CARE PROVIDER THAT ALL CURRENT EMPLOYEES ARE FREE FROM COMMUNICABLE’ DISEASE, INCLUDING TUBERCULOSIS Rule 58A-6.006(5) (b)9,. Florida Administrative Code (STAFFING STANDARD) MINOR VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. During the ‘re-licensure survey conducted on 04/04/07 and based on record review and interview with the Program Nurse, the facility failed to have a statement from a licensed health care provider that one of the two current employees was free from tuberculosis in a communicable form and signs and symptoms of other communicable diseases. 16. During the staffing standards portion of the survey, it was noted that one of the two current employees’ records reviewed (employee #2) did. not contain a statement dated within 445 days prior to beginning work in the center that the employee was free of communicable disease including tuberculosis. The program Nurse was interviewed and after investigation, confirmed the finding. 17. Based on the foregoing, North County Adult Day Care violated 58A-6.006(5) (b), Florida Administrative Code, which warrants an assessed fine of $500.00. COUNT IV NORTH COUNTY ADULT DAY CARE FAILED TO OBTAIN A BACKGROUND SCREENING FOR 1 OF THE 2 CURRENT EMPLOYEES Section 429.919(2), Florida Statutes (STAFFING STANDARD) MINOR VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. During the re-licensure survey conducted on 4/04/07 and based upon record review and interview with the Program Nurse on the day of the survey, it was revealed that the center did not obtain a background screening for 1 of 2 current employees. 20. Employee #2 was hired.on 02/07. The center did not have documentation of a satisfactory background screening for this employee, who provides basic and support services to the participants. The Program Nurse was interviewed and after investigation, confirmed the findings. 21. Based on the foregoing, North County Adult Day Care violated Section 429-919(2), Florid Statutes, which warrants an assessed fine of $500.00. CLAIM FOR 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 North County Adult Day Care on Counts I through IV. 2. Assess an administrative fine of $2,000.00 against North County Adult Day Care on Counts I through IV, 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 (2006). 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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATT f / | Assistant General Courisel Agency for Health Care Administration Spokane Bldg., Suite 103 8350 N. W. 52°¢ Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Karen Davis 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) 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 Vianey Serna-Yurkovich, Administrator, North County Adult Day Care, 5217 Northlake Boulevard, Palm Beach Gardens, Florida 33418, and to Denise M. Nieman, Registered Agent, 301 N. Olive Avenue, Suite 601, West Palm Beach, Florida 33401 on Tone 27 , 2007. SENDER: cc 2 Complete fern 2, and 3, complete: item 4 if if Restricted Delivery is desired. a Print your name and address on the So that we can return the card to you » Fron enemy Me back of te matpoe, or on Se Pont space peer ry i lee aiden ined ioe iF ic es i Vn, dane, > HFYES, enter delvery address below: CI No" ata gileaetd 3 Sami Mat O Mall. 7 1. Dh Registered Rfetum Fleceipt for Mercharidise | Olinsired Mat Ol cop.» D ; PL IZ4K/G 4. Restricted Delivery? (Extra Fee) O Yes * anton sence top 002 2440 O03 4235. b4b0

Docket for Case No: 07-003469