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AGENCY FOR HEALTH CARE ADMINISTRATION vs RENAISSANCE MANOR, INC., D/B/A RENAISSANCE MANOR, 07-005393 (2007)

Court: Division of Administrative Hearings, Florida Number: 07-005393 Visitors: 7
Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: RENAISSANCE MANOR, INC., D/B/A RENAISSANCE MANOR
Judges: DANIEL MANRY
Agency: Agency for Health Care Administration
Locations: Sarasota, Florida
Filed: Nov. 27, 2007
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Tuesday, January 8, 2008.

Latest Update: Sep. 22, 2024
STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Ol - 5 a> vs. Case No. 2007010354 RENAISSANCE MANOR, INC., d/b/a RENAISSANCE MANOR, 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 RENAISSANCE MANOR, INC., d/b/a RENAISSANCE MANOR (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2007), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of one thousand five hundred dollars ($1,500.00) based upon three repeat cited State Class III deficiencies pursuant to Section 429.19(2)(c), Florida Statutes (2007). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes (2007). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code, respectively. 4. Respondent operates an 41-bed assisted living facility located at 1401 — 16™ Street, Sarasota, Florida 34236, and is licensed as an assisted living facility, license number 5258. 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 (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, resident bedrooms designated for multiple occupancy in facilities newly licensed or renovated 6 months after 10-17-99, shall have a maximum occupancy of two persons. Resident bedrooms designated for multiple occupancy in facilities licensed prior to 10-17-99, shall have a maximum occupancy of four persons. Rule 58A-5.023(4)(c), Florida Administrative Code. 8. That pursuant to Florida law, “Renovation” is defined as “‘...additions, repairs, restoration, or other improvements to the physical plant of the facility within a 5 year period that costs in excess of 50 percent of the value of the building as reported on the tax rolls, excluding land, before the renovation.” Rule 58A-5.0131(31), Florida Administrative Code. 9. That on March 18, 2005, the Agency conducted a follow-up to the Biennial Licensure Survey of the Respondent facility. 10. That based upon observation and interview, Respondent has renovated the physical plant since October 17, 1999 and has failed to ensure that the maximum of occupancy of two (2) residents per bedroom in bedrooms designated for multiple occupancy was maintained in that three (3) residents were occupying and living in room 201 and three (3) residents were occupying and living in the first floor room of the carriage house. Said occupancy rates are contrary to the minimum requirements of law 11. That the Petitioner’s representative conducted an initial tour of the Respondent facility on February 23, 2005 and noted that three (3) residents were residing and occupying room 201 and that three (3) residents were residing and occupying the first floor room of the carriage house. 12, That the Petitioner’s representative interviewed Respondent’s administrator on February 23, 2005 who indicated as follows: a. That the room in the carriage house had once been licensed for three (3) beds; b. That the area is one large room; c. That she and her husband have been renovating the facility by placing all bathrooms on the exterior walls to allow more space in the residents’ rooms. 13. That the Petitioner’s representative interviewed Respondent’s administrator telephonically on February 25, 2005 at which time the administrator indicated that the renovations to the facility were begun in 2000 and 2001. 14. That the Petitioner’s representative observed during the survey that renovations were actively being made during the survey. 15. That the Petitioner’s representative interviewed Respondent’s cook on February 23, 2005 who indicated that the facility was planning to enlarge the kitchen in the near future. 16. That the Petitioner’s representative reviewed the records of the County Tax Collector on March 9, 2005 and noted that the taxable value of the Respondent’s physical plant, real property excluded, for the year 2000 was ninety-eight thousand four hundred dollars ($98,400.00). 17. That the Petitioner’s representative interviewed Respondent’s corporate stock owner on March 18, 2005 who indicated that the Respondent had made the following facility renovations: Phase 1 in 1999 at the cost of $21,000 and Phase 2 in 2000 for $140,000. 18. That the above referenced sums expended on renovations, as the same is defined by law, clearly exceed the 50 percent value of the building as reported on the tax roils, excluding land, before the renovation. 19. That the facility's renovation expenses in 2000 alone exceeded the 2000 accessed value of the buildings. 20. That based thereon, Respondent was required to renovate the bedrooms which house more than two (2) residents into rooms housing only two (2) or fewer residents in accord with law. 21. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 22. That the Agency provided Respondent with a mandatory correction date of April 18, 2005, 23. That on April 20, 2005, the Agency conducted a 2" follow-up to the Biennial Licensure Survey of the Respondent facility. 24. That based upon observation, the Respondent’s physical plant had been renovated since October 17, 1999, and failed to have a maximum of two (2) residents per bedroom in bedrooms designated for multiple occupancy as evidenced by three (3) residents living in room 201, and three residents living on the first floor room of the carriage house. 25. That the Petitioner’s representative conducted an initial tour of the Respondent facility on April 20, 2005 and noted that three (3) residents were residing and occupying room 201 and that three (3) residents were residing and occupying the first floor room of the carriage house. 26. That the records of the County Tax Collector reflected the taxable value of the Respondent’s physical plant, real property excluded, for the year 2000 was ninety-eight thousand four hundred dollars ($98,400.00). 27. That the Respondent’s corporate stock owner indicated on March 18, 2005 that the Respondent had made the following facility renovations: Phase 1 in 1999 at the cost of $21,000 and Phase 2 in 2000 for $140,000. 28. That the above referenced sums expended on renovations, as the same is defined by law, clearly exceed the 50 percent value of the building as reported on the tax rolls, excluding land, before the renovation. 29. That the facility's renovation expenses in 2000 alone exceeded the 2000 accessed value of the buildings. 30. That based thereon, Respondent was required to renovate the bedrooms which house more than two (2) residents into rooms housing only two (2) or fewer residents in accord with law. 31. That the Petitioner’s representative interviewed Respondent’s administrator who indicated that Respondent has applied for a waiver of this regulation from the Department of Elder Affairs. 32. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 33. That the Agency provided Respondent with a mandatory correction date of June 20, 2005. 34. That during a 3rd follow-up survey conducted December 20, 2005 the Agency determined that the Respondent had corrected the deficiency in that Respondent had obtained a limited waiver from the provisions of Rule 58A-5.023(4)(c), Florida Administrative Code, from the Department of Elder Affairs, said waiver granted fro a two (2) year period commencing August 10, 2005. A copy of said waiver is attached hereto as exhibit “A”. 35. That on August 23, 2007, the Agency conducted an Appraisal Survey of the Respondent facility. 36. That based upon interview with the facility owner, the facility which has been renovated since October 17, 1999, failed to have a maximum of 2 residents per bedroom in bedrooms designated for multiple occupancy. This is evidenced by 3 residents living in room 201 and 3 residents living in the first floor room of the carriage house. 37. That the Petitioner’s representative conducted an initial tour of the Respondent facility on August 20, 2007 and noted that three (3) residents were residing and occupying room 201 and three (3) residents were residing and occupying the first floor room of the carriage house. 38. That the Agency re-alleges and incorporates paragraphs twenty-six (26) through thirty (30) as if fully set forth herein. 39. That the Petitioner’s representative interviewed Respondent’s corporate stock owner on August 23, 2007 who indicated as flows: a. That a waiver was issued from the Department of Elder Affairs; b. That the waiver was granted until August 9, 2007; c. That there were still three (3) residents in room 201 and three (3) residents in the first floor of the carriage house; d. That property behind the Manor had been purchased and is currently being renovated for three (3) residents to have a private room. 40. That the Petitioner’s representative reviewed Respondent’s admission discharge log which reflected that thirty (30) admissions had occurred since May 2005, yet the facility did not adjust its census to reflect the limitation of two (2) residents per room requirement of law after the waiver from this requirement had expired. 41. That based thereon, Respondent was required to renovate the bedrooms which house more than two (2) residents into rooms housing only two (2) or fewer residents in accord with law and Respondent failed to complete such renovations prior to the expiration of the waiver of said requirement. 42. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class III deficiency. 43. That the Agency provided Respondent with a mandatory correction date of September 23, 2007. 44. That the same constitutes grounds for a repeat Class III deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT II 45. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 46. That pursuant to Florida law, all resident bedrooms shall open directly into a corridor, common use area or to the outside. A resident must be able to exit his bedroom without having to pass through another bedroom unless the 2 rooms have been licensed as one bedroom. Rule 58A-5.023(4)(d), Florida Administrative Code. 47. That on March 18, 2005, the Agency conducted a follow-up to the Biennial Licensure Survey of the Respondent facility. 48. That based upon observation and interview, Respondent failed to ensure that all resident bedrooms open directly into a corridor, common use, or to the outside as evidenced by four (4) residents who reside on the second floor of the carriage house where three (3) residents must enter the fourth resident's room to enter/exit the carriage house. 49. That the Petitioner’s representative conducted an initial tour of the Respondent facility on February 23, 2005 and noted as follows: a. That four (4) residents reside and live on the second floor of the carriage house; b. That the carriage house is a freestanding building on the campus; c. That upon entering the second floor, there is a room with a bed to the right of the door; d. That a resident resides in this room; e. That the door to the bathroom is located on an exterior wall of this room; f. That to the left of the front door is a small room with no door in place; a curtain is draped over a rod; g. That a second resident resides in this room; h. That facing the front door is another room with two beds and a wardrobe separating the beds; i. That a third and fourth resident reside in this room; j. That in order for three (3) of the four (4) residents to enter/exit and/or use the bathroom, they must pass through a resident's room; k. That because of the walls being from the ceiling to the floor, and abutting in 90- degree angles, there are three distinct rooms in this area. 50. That the Petitioner’s representative interviewed Respondent’s Administrator on February 23, 2005 who indicated as follows: a. That four (4) residents reside on the second floor of the carriage house; b. That the area was licensed as a single room; c. That she was unable to produce a floor plan that was submitted for licensure; d. That the bathroom was renovated in either 2000 or 2001. 51. That this area had not been licensed as a single room. 52. That the failure to ensure that all resident bedrooms open directly into a corridor, common use area or to the outside and that each resident is able to exit his bedroom without having to pass through another bedroom unless the two rooms have been licensed as one bedroom is in violation of law. 53. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 34, That the Agency provided Respondent with a mandatory correction date of March 25, 2005. 55. That on April 20, 2005, the Agency conducted a 2"4 follow-up to the Biennial Licensure Survey of the Respondent facility. 56. That based upon observation and interview, Respondent failed to ensure that all resident bedrooms open directly into a corridor, common use, or to the outside as evidenced by four (4) residents who reside on the second floor of the carriage house where three (3) residents must enter the fourth resident's room to enter/exit the carriage house. 57. That the Petitioner’s representative conducted an initial tour of the Respondent facility on April 30, 2005 and noted as follows: a. That four (4) residents reside and live on the second floor of the carriage house; b. That the carriage house is a freestanding building on the campus; c. That upon entering the second floor, there is a room with a bed to the right of the door; d. That a resident resides in this room; e. That the door to the bathroom is located on an exterior wall of this room; f. That to the left of the front door is a small room with no door in place; a curtain is draped over a rod; g. That a second resident resides in this room; h. That facing the front door is another room with two beds and a wardrobe separating the beds; i. That a third and fourth resident reside in this room; j. That in order for three (3) of the four (4) residents to enter/exit and/or use the bathroom, they must pass through a resident's room; k. That because of the walls being from the ceiling to the floor, and abutting in 90- degree angles, there are three distinct rooms in this area. 58. That this area had not been licensed as a single room. 59. That the failure to ensure that all resident bedrooms open directly into a corridor, common use area or to the outside and that each resident is able to exit his bedroom without having to pass through another bedroom unless the two rooms have been licensed as one bedroom is in violation of law. 10 60. That the Petitioner’s representative interviewed Respondent’s administrator who indicated that the Respondent has applied for a waiver of this regulation from the Department of Elder Affairs. 61. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 62. That the Agency provided Respondent with a mandatory correction date of June 20, 2005. 63. That during a 3rd follow-up survey conducted December 20, 2005 the Agency determined that the Respondent had corrected the deficiency. 64. That on August 23, 2007, the Agency conducted an Appraisal Survey of the Respondent facility. 65. That based upon observation and interview, Respondent failed to ensure that all resident bedrooms open directly into a corridor, common use, or to the outside as evidenced by four (4) residents who reside on the second floor of the carriage house where three (3) residents must enter the fourth resident's room to enter/exit the carriage house. 66. That the Petitioner’s representative conducted an initial tour of the Respondent facility on August 23, 2007 and noted as follows: a. That four (4) residents reside and live on the second floor of the carriage house; b. That the carriage house is a freestanding building on the campus; c. That upon entering the second floor, there is a room with a bed to the right of the door; d. That a resident resides in this room; e. That the door to the bathroom is located on an exterior wall of this room; 11 67. That to the left of the front door is a small room with no door in place; a curtain is draped over a rod; That a second resident resides in this room; That facing the front door is another room with two beds and a wardrobe separating the beds; That a third and fourth resident reside in this room; That in order for three (3) of the four (4) residents to enter/exit and/or use the bathroom, they must pass through a resident's room; That because of the walls being from the ceiling to the floor, and abutting in 90- degree angles, there are three distinct rooms in this area. That the Petitioner’s representative interviewed Respondent’s corporate stock owner on August 23, 2007 who indicated as follows: 68. a. b. That a waiver had been issued from the Department of Elder Affair; That the waiver was granted until August 9, 2007; That there were still four (4) residents living on the second floor of the carriage house; That property behind the Manor had been purchased and is currently being renovated for three (3) residents to have a private room. That the failure to ensure that all resident bedrooms open directly into a corridor, common use area or to the outside and that each resident is able to exit his bedroom without having to pass through another bedroom unless the two rooms have been licensed as one bedroom is in violation of law. 12 69. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class III deficiency. 70. That the Agency provided Respondent with a mandatory correction date of September 23, 2007. 71. That the same constitutes grounds for a repeat Class III deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT III 72. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 73. That pursuant to Florida law, sole access to a toilet or bathtub or shower shall not be through another resident’s bedroom, except in apartments within a facility. Rule 58A- 5.023(5)(d), Florida Administrative Code. 74. That on March 18, 2005, the Agency conducted a follow-up to the Biennial Licensure Survey of the Respondent facility. 75. That based upon observation and interview, Respondent failed to ensure sole access to a toilet or bathtub or shower shall not be through another resident's bedroom, except in apartments within a facility as evidenced by a resident in room 202 and three (3) residents on the second floor of the carriage house not having access to the bathroom without going through another resident's bedroom, and is in violation of law. 76. The Agency re-alleges and incorporates paragraphs forty-nine (49) through fifty-one (51) as if fully set forth herein. 77. That the Petitioner’s representative observed on February 23, 2005 during a tour of the facility as follows: a. That three (3) residents reside and occupy room 202 on the second floor of the facility; b. That two (2) residents reside in the front of the room; c. That there is a full wall with a doorway with no door approximately two-thirds distance from the front door; d. That a third resident resides behind this wall; e. That the third resident must pass through the front room to enter/exit and/or use the bathroom. 78. That the Petitioner’s representative interviewed Respondent’s administrator on February 23, 2005 who indicated that both room 202 and the second floor of the carriage house were licensed as one (1) room prior to facility renovation. 79. That the failure to ensure that sole access to a toilet or bathtub or shower is not through another resident’s bedroom, except in apartments within a facility, is in violation of law. 80. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 81. That the Agency provided Respondent with a mandatory correction date of March 25, 2005. 82. That on April 20, 2005, the Agency conducted a 2" follow-up to the Biennial Licensure Survey of the Respondent facility. 83. That based upon observation and interview, Respondent failed to ensure sole access to a toilet or bathtub or shower shall not be through another resident's bedroom, except in apartments within a facility as evidenced by a resident in room 202 and three (3) residents on the second floor of the carriage house not having access to the bathroom without going through another resident's bedroom, and is in violation of law. 84. | The Agency re-alleges and incorporates paragraphs fifty-seven (57) through fifty-eight (58) as if fully set forth herein. 85. That the Petitioner’s representative observed on April 20, 2005 during a tour of the facility as follows: a. That three (3) residents reside and occupy room 202 on the second floor of the facility; b. That two (2) residents reside in the front of the room; c. That there is a full wall with a doorway with no door approximately two-thirds distance from the front door; d. That a third resident resides behind this wall; e. That the third resident must pass through the front room to enter/exit and/or use the bathroom. 86. That the Petitioner’s representative interviewed Respondent’s administrator who indicated that the Respondent has applied for a waiver of this regulation from the Department of Elder Affairs. 87. That the failure to ensure that sole access to a toilet or bathtub or shower is not through another resident’s bedroom, except in apartments within a facility, is in violation of law. 88. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 89. That the Agency provided Respondent with a mandatory correction date of June 20, 2005. 90. That during a 3rd follow-up survey conducted December 20, 2005 the Agency determined that the Respondent had corrected the deficiency. 91. That on August 23, 2007, the Agency conducted an Appraisal Survey of the Respondent facility. 92, That based upon observation and interview, Respondent failed to ensure sole access to a toilet or bathtub or shower shall not be through another resident's bedroom, except in apartments within a facility as evidenced by a resident in room 202 and three (3) residents on the second floor of the carriage house not having access to the bathroom without going through another resident's bedroom, and is in violation of law. 93. That the Petitioner’s representative conducted an initial tour of the Respondent facility on August 23, 2007 and noted as follows: a. That four (4) residents reside and live on the second floor of the carriage house; b. That the carriage house is a freestanding building on the campus; c. That upon entering the second floor, there is a room with a bed to the right of the door; d. That a resident resides in this room; e. That the door to the bathroom is located on an exterior wall of this room; f. That to the left of the front door is a small room with no door in place; a curtain is draped over a rod; g. That a second resident resides in this room; h. That facing the front door is another room with two beds and a wardrobe separating the beds; i. That a third and fourth resident reside in this room; j. That in order for three (3) of the four (4) residents to enter/exit and/or use the bathroom, they must pass through a resident's room; k. That because of the walls being from the ceiling to the floor, and abutting in 90- degree angles, there are three distinct rooms in this area. 94. That the Petitioner’s representative observed on August 23, 2007 during a tour of the facility as follows: a. That three (3) residents reside and occupy room 202 on the second floor of the facility; b. That two (2) residents reside in the front of the room; c. That there is a full wall with a doorway with no door approximately two-thirds distance from the front door; d. That a third resident resides behind this wall; e. That the third resident must pass through the front room to enter/exit and/or use the bathroom. 95. That the Petitioner’s representative interviewed Respondent’s corporate stock owner on August 23, 2007 who indicated as follows: a. That a waiver had been issued from the Department of Elder Affair; b. That the waiver was granted until August 9, 2007; c. That there were still four (4) residents living on the second floor of the carriage house; d. That property behind the Manor had been purchased and is currently being renovated for three (3) residents to have a private room. 17 96. That the failure to ensure that sole access to a toilet or bathtub or shower is not through another resident’s bedroom, except in apartments within a facility, is in violation of law. 97. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class III deficiency. 98. That the Agency provided Respondent with a mandatory correction date of September 23, 2007. 99. That the same constitutes grounds for a repeat Class III deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). Respectfully submitted this A day of October, 2007. Pax Le A. Walsh No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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, FL 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. 18 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7007 0710 0004 0429 1983 on October Zh, 2007 to Heather Eller, Administrator, Renaissance Manor, 1401 — 16" Street, Sarasota, Florida 34236 and by U.S. Mail to J. Scott Eller, Registered Agent, Renaissance Manor, Inc., 671 Mecca Drive, Sarasota, FL 34236. Copies furnished to: a fe Zt Thepias J: Seriiof Attorney Heather Eller, Administrator Renaissance Manor 1401 - 16™ Street Sarasota, Florida 34236 (U.S. Certified Mail) J. Scott Eller, Registered Agent Renaissance Manor, Inc. 671 Mecca Drive Sarasota, FL 34236 (U.S. Mail) Kriste Mennella/Donna Houk Field Office Manager 2295 Victoria Ave., Room 340 Ft. Myers, Florida 33901-3884 (U.S. Mail) Thomas J. Walsh, II, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) 19 SENDER: Compig COMPLETE Tis: SEC, . 1B Complete items 1, 2, and 3. Also complete 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 mailpiece, or on the front if space permits, 1. Article Addressed to: er Admin: f { Heather Ell Renaissance Manor WMO\ = IU Greet Sa en é rl. B42 Sarasobe, Fl. BA23¢ ON DELIVERY 3. Service Type O Certified Mal 0 Express Mail C Registered C1 Retum Recelpt for Merchandise Clinsured Mall =O C.0.D. S_ 2. Article Number oO? (Transfer from Smee! HE ae PS Form 3811, February 2004 Domestic Return Recelpt 102595-02-M-1540

Docket for Case No: 07-005393
Source:  Florida - Division of Administrative Hearings

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