Op ig STATE OF FLORIDA “> &y AGENCY FOR HEALTH CARE ADMINISTRATION. by 7) Aur b To, . STATE OF FLORIDA, Bigle , ae AGENCY FOR HEALTH CARE 0 ‘2 6) ga | “Ainpghg ie ADMINISTRATION, OS Me Petitioner, v. Case No. 2007014083 MARYDALE, INC,, d/b/a MARYLAND MANOR, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration, (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Marydale, Inc. d/b/a Maryland Manor (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to revoke its license and to impose an administrative fine in the amount of four thousand five hundred dollars ($4,500.00) and to assess a survey fee in the amount of one hundred sixty-one dollars and fifty cents ($161.50), based upon four class II violations and one repeat class III violation. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2007). 3. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities, Ch. 408, Part If, Ch. 429, Part I, Fla. Stat, (2007); Ch. 58A-5, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2007). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility. § 429,19(7), Fla. Stat. (2007). 5. The Respondent was issued a standard license by the Agency (License Number 7165) to operate a 21-bed assisted living facility located at 7632 Maryland Avenue, Hudson, Florida 34667 (hereinafter “the Facility”), and was at all times material required to comply with the applicable state statutes and rules governing such facilities. Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who are unable to live independent-ly, These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Assisted living facilities are regulated in a manner So as to encourage dignity, individuality, and choice for residents, while providing them a reasonable assurance for their health, safety and welfare. Generally, assisted living facilities provide supervision, assistance with personal care and supportive services, as well as assistance with or administration of medications to residents who require such services. 6. In addition to its standard license, the Respondent was issued a specialty license to provide limited mental health services to mental health residents at the Facility. § 429.075, Fla, Stat. (2007). “Mental health resident” means an individual who receives social security disability income due to a mental disorder as determined by the Social Security Administration or receives supplemental security income due to a mental disorder as determined by the Social Security Administration and receives optional state supplementation. § 429.02(15), Fla. Stat. ~ (2007). COUNT I REVOCATION OF LICENSE The Respondent Committed An Intentional Or Negligent Act Materially Affecting The Health Or Safety Of A Client, And/Or Committed A Violation Of The Authorizing Statutes Or The Applicable Rules for Assisted Living Facilities In Violation Of F.S. 408.815(1)(b) and (c) 7, The Agency re-alleges and incorporates by reference paragraphs 1 through 6. 8. Under Florida law, in addition to the grounds provided in the authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: committing an intentional or negligent act materially affecting the health or safety of a client or provider, and committing a violation of Chapter 408, Part IJ, Florida Statutes (the Health Care Licensing Procedures Act), the authorizing statutes (Chapter 429, Part I, Florida Statues), or the applicable tules (Chapter 58A-5, Florida Administrative Code). § 408.815(1)(c), Fla. Stat. (2007). 9. "Controlling interest" means “the applicant or licensee.” § 408.803(7)(a), Fla. Stat. (2007). 10. “Licensee” means an individual, corporation, partnership, firm, association, or governmental entity that is issued a permit, registration, certificate, or license by the agency. The licensee is legally responsible for all aspects of the provider operation. § 408.803(9), Fla. Stat. (2007). 11. "Client" means any person receiving services from a provider listed in Section 408.802, Florida Statutes. § 408.803(6), Fla. Stat. (2007). 12. "Provider" means any activity, service, agency, or facility regulated by the Agency and listed in Section 408.802, Florida Statutes, § 408.803(6), Fla. Stat. (2007). 13. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR #2007013848). 14, The Agency re-alleges and incorporates by reference Count III through Count VII as set forth below. . 15. As a result of this complaint survey, the Agency cited the Respondent for four class II violations and one repeat class III violation, as set forth below. 16. These cited violations constituted intentional or negligent acts that materially affected the health or safety of a client of the Respondent or its Facility. 17, These cited violations constituted violations of the authorizing statutes and applicable rules for assisted living facilities, WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to revoke the license of the Respondent to operate the above- referenced assisted living facility. COUNT IT REVOCATION OF LICENSE The Respondent Was Cited For Three Or More Class II Violations During A Single Survey In Violation Of F.S. 429.14(1)(a) 18. The Agency re-alleges and incorporates by reference paragraphs | through 6. 19. Under Florida law, in addition to the requirements of Part Il of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this Part and impose an administrative fine in the manner provided in Chapter 120 against a licensee of an assisted living facility for a violation of any provision of this Part, Part II of Chapter 408, or applicable tules, or for any of the following actions by a licensee of an assisted living facility, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: a citation of three or more class II violations as defined in Section 429.19, Florida Statutes. § 429.14(1)(e)2, Fla. Stat. (2007). 20. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2007013848), 21. The Agency re-alleges and incorporates by reference Count I through Count VI as set forth below. 22. As a result of this complaint survey, the Agency cited the Respondent for four class II violations. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to revoke the license of the Respondent to operate the above- referenced assisted living facility. COUNT Il (Tag 626) The Respondent Failed To Have Medications Stored and Labeled Properly In Violation Of F.A.C. 58A-5.0185(7)(a) 23. The Agency re-alleges and incorporates by reference paragraphs 1 through 6. 24. Under Florida law, no prescription drug shall be kept or administered by the facility, including assistance with self-administration of medication, unless it is properly labeled and dispensed in accordance’ with Chapters 465 and 499, Florida Statutes, and Rule 64B16- 28.108, Florida Administrative Code. If a customized patient medication package is prepared for a resident, and separated into individual medicinal drug containers, then the following informa- tion must be recorded on each individual container: 1. The resident’s name and 2. Identification of each medicinal drug product in the container. Fla. Admin. Code R. 58A-5.01 85(7)(a). 25. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2007013848). 26. Based upon staff interview and observation of the residents’ centrally stored medications on December 11, 2007, the Respondent was storing medications that had not been properly labeled and dispensed in accordance with Chapters 465 and 499, Florida Statutes, and Rule 64B16-28.108, Florida Administrative Code, for 13 of 13 sampled residents (#1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 16). Only 13 different residents were identified because some of the cups were in bins labeled with residents names twice (#1, 16). One bin had a first name only. 27. Based upon observation of the medication cabinet in the kitchen where residents medications are stored on December 11, 2007, at approximately 5:00 PM, there were numerous small paper and plastic cups observed stacked together for 13 mental health residents. 28. Each cup contained multiple pills of varying shapes, sizes and colors. 29. According to the staff person interviewed at this time, she had filled these small cups at 12:00 noon. , 30. Some of the medications were to be given to the residents at 5:00 PM and bedtime later that day and some were to be given to the residents during the morning on the following morning. 31. This medication practice could potentially result in a resident receiving the wrong medication dosage because there was no way to determine what medications were in each cup. 32. Further, the cups did not identify which residents they belonged to, which added to the potential for residents receiving the wrong medications. 33. | The Respondent’s actions and/or inactions constituted a Class IT violation. 34. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. § 429.19(2)(b), Fla. Stat. (2007). 35. | The Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). COUNT IV (Tag 718) The Respondent Violated The Resident’s Right To Live In A Safe And Decent Living Environment, Free From Abuse And Neglect, And Violated The Resident’s Right To Be Treated With Due Recognition Of Personal Dignity, Individuality, And The Need For Privacy In Violation Of F.S. 429.28(1) 36. The Agency re-alleges and incorporates by referenced paragraphs 1 through 6. 37.....-Under Florida law, no resident of an assisted living facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of the facility. § 429.28(1), Fla. Stat. (2007). Every resident of an assisted living facility shall: have the right to live in a safe and decent living environment, free from abuse and neglect, and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. § 429.28(1)(a)-(b), Fla. Stat. (2007). 38. Onor about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2007013848). 39. Based upon observation during a tour of the Facility on December 11, 2007, between 1:30 PM and 6:00 PM, the Respondent failed to ensure that residents were provided with a safe and decent living environment, free from abuse and neglect, and failed to ensure that its residents were treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. 40. There were 18 residents in the Facility at the time of this visit, all of which were mental health residents as defined by statute. 41. _ A tour of the Facility revealed that the physical environment throughout the entire assisted living facility was dirty, odorous and in significant disrepair. 42. Numerous health code and fire safety violations were noted by the local health department. 43. There existed a lack of general supervision on the part of staff to ensure residents were provided the guidance and direction to support the mental health care services needed, such as (a) ensuring that residents’ clothing was clean and odor free, (b) ensuring that residents’ yooms were maintained in a clean and safe condition, (c) ensuring that residents were provided meals that were nutritional and wholesome, and (d) ensuring that residents’ medications were properly stored and managed. 44. The residents’ rooms throughout the Facility had dirty floors and dirty clothes and other items littered on the floors. 45, In the Facility’s common area or television room, the flooring lacks base boards in several areas. They had areas with missing base boards that revealed a thick dark growth that appeared to be mold or mildew. 46. In one resident’s room, the smoke detector has been dismantled or removed. In its stead loose wires hang from the fixture. 47, In the main corridor of the Facility, there were walls that were caked with dirt and/or grime. 48. Several smears of an unidentified, but clearly unintended, brown substance were obvious.on the corridor walls. 49. Resident room #5 has a large discolored area of the ceiling that appeared to be water damage. 50. Resident room #10 has an area where the wallboard has been removed as a result of a leak and moisture damage. 51. In the open area exposed by the wallboard’s removal, pipes are thick with a green growth identified by Respondent’s staff member as a green mold. 52. The bathroom abutting resident room #10 contains a tiled shower and floor. The grout between the tiles is thick with a black mold or mildew. The shower was disconnected. 53. Floor coverings were stained and torn. 54. Furnishings were dirty and/or stained. 55. Mold was observed in various areas of the Facility. 56. The kitchen area was not maintained to ensure that eating utensils, tableware and cooking utensils could be adequately washed. 57. There were no handles on the faucets of the 3 compartment sink. 58. Food storage areas were not maintained to ensure that food items were stored at proper temperatures. 59. During the entire time of this visit, residents were observed to be wandering around the home, sitting without activity, sleeping or outside smoking. 60. Several residents were observed to be in clothing that did not appear clean. 61. Resident #2 approached the surveyors upon arrival showing two colored wrist bands (orange and white) affixed to on his or her arm. 62. One of the bands had the names of psychotropic medications printed on it, the other had what appeared to be information identifying the resident. 63. The resident was unable to tell the surveyor when he or she had been discharged from the hospital and was not able to coherently answer any questions. 64, The Facility staff had made no effort to remove the hospital wrist bands from the Resident after the resident had returned to the Facility, which evidenced a disregard for the resident’s dignity. 65. The Respondent’s actions and/or inactions constituted a Class II violation. 66. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. § 429.19(2)(b), Fla. Stat. (2007). 67. The Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). COUNT V (Tag 801) The Respondent Failed To Ensure That All Food Services Were Provided In A Safe And Sanitary Manner In Violation Of F.A.C. 58A-5.020(1)(b) 68. The Agency re-alleges and incorporates by reference paragraphs 1 through 6. 69. Under Florida law, when food service is provided by the assisted living facility, the administrator or a person designated in writing by the administrator, shall be responsible for total food services and the day-to-day supervision of food services staff, and perform his or her duties in a safe and sanitary manner. Fla. Admin. Code R. 58A-5.020(1)(a)-(b). 70. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2007013848). 71. Based upon observation of the food service area of the Facility, the administrator failed to ensure that all food service was provided in a safe and sanitary manner. 72. An observation of the kitchen revealed that the three-compartment sink was not functional for staff to wash, rinse and sanitize food preparation supplies and eating ware. 73. The handles to the faucets were missing. 74. One faucet had a wrench affixed to it in-order to turn the water on and off. 75. Dirty pots and other dirty items were observed in the sink. 76. A large garbage can without a lid was positioned next to the stove was full to the top of old food stuffs and other items. 77. The refrigerator/freezer units in the dining room were without thermometers. 78. The refrigerator/freezer units had splattered food, liquid debris and areas of rust. 79. No light illuminated when the refrigerator door was opened. 80. Flies were observed though-out the facility. 81. The area where the non-perishable food supply was stored had walls heavily covered in black mold/mildew as well as a very dirty floor. 82. Inside the refrigerator, mold was observed on food products. 83. A sister Agency measured the inside temperature of the refrigerator at 50 degrees, well above the minimum temperature required to-ensure food preservation. 84. The Respondent’s actions and/or inactions constituted a Class II violation. 85. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. § 429.19(2)(b), Fla. Stat. (2007). 86. The Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). COUNT VI (Tag 1001) The Respondent Failed To Ensure That The Facility Was Equipped And Maintained To Ensure The Safety, Supervision And Promote A Home Like Environment For The Residents In Violation Of F.A.C. 58A-5.023(1)(a) 87. The Agency re-alleges and incorporates by referenced paragraphs 1 through 6. 88. Under Florida law, an assisted living facility shall be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents. Fla. Admin. Code R. 58A-5.023(1)(a). 89. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2007013848). 90. Based upon observation during a tour of the Facility on December 11, 2007, the Facility was not equipped and maintained to promote a residential, non-medical environment and provide for the safety, supervision of the residents. 91. The Facility was found to be generally dirty and required repair throughout. 92. Floors, walls, electrical and plumbing fixtures were not properly functioning. 93. Odors were observed throughout, either from poor cleaning practices or poor resident hygiene. 94. Two of four resident bathrooms were not operational. 95. Residents clothing was not laundered and cleaned. 96. | Mold was observed in various locations throughout the Facility, in the kitchen area and in areas other than the kitchen. 97. In one of the restrooms, the tile caulking was thick with the growth of dark mold or mildew. 98. The lighting fixture over the sink area lacked two of three bulbs. 99. The exterior grounds were observed to be littered with trash and cigarette butts. 100. The rear of the property had grass that was knee high. 101. A shed in the rear of the facility was piled with old, mildewed upholstered furniture and bedding. 102. The floor to this shed had rotten floor boards and the ceiling was caving in. 103. The door to the shed unlocked making it accessible to any of the residents. 104. The kitchen area had non-functioning sink faucets, making it impossible to wash, rinse and sanitize the dishes and cooking utensils. 105. Flies were observed throughout the Facility. 106. The Respondent’s actions and/or inactions constituted a Class II violation. ; 107. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. § 429.19(2)(b), Fla. Stat. (2007). 108. The Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). COUNT VU (Tag 1005) The Respondent Failed To Ensure That All Furniture And Furnishings Were Clean, Functional, Free-of-Odors And In Good Repair In Violation Of F.A.C. 58A-5.023(1)(b) 109. The Agency re-alleges and incorporates by reference paragraphs 1 through 6. 110. Under Florida law, an assisted living facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shali be repaired or replaced. Windows, doors, plumbing, and appliances shall be functional and in good working order. All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled. for safety reasons provided they are functionally available when needed. Fla. Admin. Code R. 58A-5.023(1)(b). 111. On or about March 24, 2006, the Agency conducted a complaint survey of the Respondent and its Facility (CCR# 2006002234). 112. Based upon observation and interview, the Respondent failed to ensure that the furniture for Resident #2 was in good working order and that the room was free of dirt, debris and foul odors. 113. During a tour of the Facility, it was observed that resident room #2 was dirty. 114. The floor of the room was filthy and the room was cluttered with debris. 115. The top drawer of the dresser was broken. 116. During an interview with the caregiver on March 24, 2006, at approximately 9:15 a.m., it was confirmed that the room was dirty and that the dresser drawer was broken. 117. The Respondent’s actions and/or inactions constituted a class III violation. 118. Class “III” violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class J or class II violations. § 429.19(2)(c), Fla. Stat. (2006). 119. The Agency cited the Respondent for a Class III violation. 120. The Respondent was given a mandatory correction date of March 27, 2006. 121. On or about December 11, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR #2007013848). 122. Based upon a tour of the Facility on December 11, 2007, all of the furniture and furnishings were not maintained in clean condition and free from odors. 123. In resident room #1, the dresser top was dirty and stained. 124. In addition, the tub caulking in the hall bathroom was badly discolored and was black with mildew. 125. Inresident room #3, the door did not have a doorknob. 126. In addition, only a locking mechanism which could be turned with a key from the exterior side. 127. From the interior side of the door the resident only had a thump latch. 128. In resident room #4, the curtains were badly discolored and dirty looking. 129. In addition, the bed mattress was stained. 130. Inresident room #8, the ceiling air conditioning vents were rusted. 131. In resident rooms #1, #4, #8, #9 and #12, the floors were littered with debris and 132.. Inresident rooms #4, #8 and #9, strong offensive odors were evident. 133. The floor of resident room #12 was saturated with clutter and trash. 134. Resident room #1 has a linoleum or vinyl flooring. 135. This flooring in the rooms had several areas that were ripped or torn. 136, The rips or tears in the flooring presenting an opportunity for resident tripping and inhibited the cleaning of the flooring. 137. In addition, the ceiling of this room has obvious thick yellow streaks that are unintended and appear to be the bleeding of structural beams located above the ceiling material’s substance. 138. Resident room #9 was cluttered with soiled clothing. 139. The residents of this room indicated that clothes are washed only upon request. 140, The hallway off these rooms has several holes in the wallboard of approximately one inch in diameter exposing the air to dust or dirt within the confines of the walls. 141. Resident room #7 either has no light in the room or the light is inoperable. 142. The finish of the room’s ceiling appeared to be peeling from the ceiling and falling from its hold. 143. The Respondent’s actions and/or inactions constituted a class II violation. 144. Class "III" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. § 429.19(2)(c), Fla. Stat. (2007). 145, The Agency cited the Respondent for a Class III violation. 146. The Respondent was given a mandatory correction date of January 11, 2008. 147. The Respondent’s violation constituted a repeated class III violation. 148. The Agency shall impose an administrative fine for a cited class II violation in an 16 amount not less than $500 and not exceeding $1,000 for each violation. § 429.19(2)(c), Fla. Stat. (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500.00). COUNT VIII Assessment of Survey Fee 149. The Agency re-alleges and incorporates by reference paragraphs 1 through 6, 150. Under Florida law, the Agency is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under.429,.28(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(7), Fla. Stat. (2007). 151. The Agency received a complaint about the Respondent’s Facility. 152. As aresult of the complaint, the Agency conducted a complaint survey of the Respondent’s Facility on or about December 11, 2007. 153. As aresult of the complaint survey, the Respondent was cited for violations that were the subject of the complaint, as set forth above. 154. In this case, the Agency is authorized to assess a survey fee in the amount of one hundred and sixty-one dollars and fifty cents ($161.50). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose a survey fee against the Respondent in the amount of one hundred and sixty-one dollars and fifty cents ($161.50). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Revoke the Respondent’s license to operate this assisted living facility. 3. Impose an administrative fine against the Respondent in the total amount of four thousand five hundred dollars ($4,500.00). 4. Assess a survey fee against the Respondent in the af sixty-one dollars and fifty cents ($161.50). 5. Enter any other relief that this Court deems ft Respectfully submitted this 28th day of De€embe Ate; Florida Bar No. 7093 11 Agency for Health Care Administration Office of the General Counsel The Sebring Building, Suite 330D 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Copies furnished to: land Manor, Receipt No. frydale, Inc., 791 Thomas M. Hoeler, SenterAttorney Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel The Sebring Building, Suite 330D 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 Bing Santiano, Administrator Kathleen Varga Maryland Manor Facility Evaluator Supervisor 7632 Maryland Avenue Agency for Health Care Administration Hudson, Florida 34667 (U.S. Certified Mail) 525 Mirror Lake Drive North, Fourth Floor St. Petersburg, Florida 33701 791 Weathersfield Drive Dunedin, FL 34698 \" .S. Certified Mail) (Interoffice) Bing Santiano, Registered Agent Thomas M. Hoeler, Senior Attorney Marydale, Inc. Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701 _| Lateroffice) COMPLETE THIS SECTION OALDELIVERY * & 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 mallplece, or on the front if space permits, 1, Article Addressed ta: : Bung Santrano, Adwin. Mary land Maner Te 32 Mary land Ave. Hudson, FL 34647 A. Signature X Qa tf. B, Recelved by (Printed Nama) D, is delivery address different from item 1? (0 Yes If YES, enter delivery address below: 1 No 3. Service Type © Certified Mall 1 Express Mall seat! Ci Registered 0 Retum Recelpt for Merchandise*' O insured Mat =O co. 4, Restricted Dalivery? (Extra Fea) O Yes “fee 7007 O720 oo04 429 ayy, 2007014 083 © Oe j PS Form 3811, February 2004 Domestic Retum Recelpt ~ "493895-02-M-1540 TT ee = SENDER: COMPLETE THI ® Complete Items 1, 2, and 3, Also complete tern 4 if Restricted Delivery Is desired. : ml Print your name and address on the reverse so that we can return the card to you. . i Attach this card to the back of the mallpiece, ‘ eron the front if space permits. 1. Article Addressed to: G. Date of pagy > HY D, Is delivery address different from item ae IfYES, enter evry cap pio “So Bing Santana, fig. Agué ~, bo, ma dole, ir G 3. Service Type © certified Mall C1 O Registered Ci insured Mall (C1 G.0.D. 4. Restricted Delivery? (Extra Fee) O Yes 700? O7L0 oo04 o4@4 2423 TH 20070140 €3 | 2 Article h (Transfei. ... PS Form 3811, February 2004 _ Domestic Retum Recelpt 102595-02-M-1540

Docket for Case No: 08-000621