STATE OF FLORIDA el L E D AGENCY FOR HEALTH CARE ADMINISTRATION hf OcT STATE OF FLORIDA, - 16 PH 3: AGENCY FOR HEALTH CARE \ » “] s) 4 Di VISION g ADMINISTRATION, - OS rR AT) VE GS Petitioner, vs. Case No. 2008007513 ALTERNATE FAMILY CARE, INC. d/b/a PINEWOOD GROUP HOME, 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, ALTERNATE FAMILY CARE, INC. d/b/a PINEWOOD GROUP HOME (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine against a residential treatment center for children and adolescents in the amount of ONE THOUSAND FIVE HUNDRED DOLLARS ($1,500.00) pursuant to Section 394.879(4), Florida Statutes (2007) based upon three (3) uncorrected violations. 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 394, Part IV, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees residential treatment centers and enforces the applicable federal and state regulations, statutes and rules governing such facilities. Chapter 408, Part II, and Chapter 394, Part IV, Florida Statutes (2007); Chapter 65E-9, Florida Administrative Code. The Agency may deny, suspend or revoke a license or impose reasonable restrictions on any portion of a license issued to a residential treatment center. Sections 408.813, 408.815, 394.902, Florida Statutes (2007). The Agency may also impose an administrative penalty on any licensee that violates the rules adopted for residential treatment facilities. Section 394.879(4), Florida Statutes (2007). 5. The Respondent was issued a license by the Agency (License No. 6) to operate an eight (8) bed residential treatment center for children and adolescents located at 4055 Pinewood Road, Melbourne, Florida 32935, and was required at all material times to comply with the applicable federal and state regulations, statutes and rules governing residential treatment facilities. COUNT I The Respondent Failed Ensure That The Individual Record For Each Resident Contained The Required Items In Violation of Rule 65E-9.006(12)(b) and (c), Florida Administrative Code 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, the provider shall develop an individualized record for each child. The form and detail of the records may vary but shall, at a minimum, include: 1. Identification and contact information, including the child's name, date of birth, Social Security number, gender, race, school and grade, date of admission, and the parent or guardian’s name, address, home and work telephone numbers; 2. Source of referral; 3. Reason for referral to residential treatment, e.g., chief complaint, presenting problem(s); 4. Record of the complete assessment; 5. DSM diagnosis; 6. Treatment plan; 7. Medication history; 8. Record of medication administered by program staff, including type of medication, dosages, frequency of administration, persons who administered each dose, and method of administration; 9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, such as emergency rooms or general hospitals; 10. Progress notes; 11. Treatment summaries; 12. Consultation reports; 13. Informed consent forms; 14. A chronological listing of previous placements, including the dates of admission and discharge, and dependency and delinquency actions affecting the minor's legal status; 15. Written individual education plan for the child, when applicable; 16. The discharge summary, which shall include the initial diagnosis, clinical summary, treatment outcomes, assessment of child's treatment needs at discharge, the name, address and phone number of person to whom the child was discharged and follow-up plans. In the event of death, a summary shall be added to the record and shall include circumstances leading to the death. All discharge summaries shall be signed by the clinical or medical director; 17. For out of state children, copies of completed interstate compact ICPC 100A and ICPC 100B forms (February 2002) and a copy of each Interstate Compact Transmittal Memorandum and any attachments thereto that were sent to the Residential Treatment Center by the Department of Children and Families Interstate Compact on the Placement of Children Office; 18. Documentation of any use of restraint, seclusion or time out; 19. A copy of each incident report that includes a clear description of each incident; the time, place, and names of individuals involved; witnesses; nature of injuries, if any; cause, if known; action(s) taken; a description of medical services provided, if any; by whom such services were provided; and any steps taken to prevent a recurrence. Incident reports shall be completed by the individual having first hand knowledge of the incident, including paid and volunteer staff, emergency or temporary staff, and student interns; and 20. Documentation that all of the various notices and copies required by Florida Administrative Code Rules were properly given. Rule 65E-9.006(12)(b), Florida Administrative Code. Records of discharged children shall be completed within 15 business days following discharge. Rule 65E-9.006(12)(c), Florida Administrative Code. 8. On or about March 11, 2008 the Agency conducted a Complaint Investigation (#2008002968) of the Respondent’s facility. 9. Based on record review and interview, the facility failed to ensure that the individual record for each resident contained the required items for four (4) of five (5) sampled residents, Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5), currently residing in the facility and one (1) discharged resident, Resident number one (1). 10. A review of Resident number two’s (2) red folder and blue notebook revealed that the facility did not have progress notes documenting behaviors, incidents or the use of physical restraints, visitation plan or schedule with family/foster family, progress notes, treatment summaries, and treatment plan. 11. A review of Resident number three’s (3) red folder and blue notebook revealed that the facility did not have progress notes documenting behaviors, incidents or the use of physical restraints or visitation plan or schedule with family/foster family, progress notes, treatment summaries, and treatment plan. 12. A review of Resident number four’s (4) red folder and blue notebook revealed that the facility did not have progress notes documenting behaviors, incidents or the use of physical restraints or visitation plan or schedule with family/foster family, progress notes, treatment summaries, and treatment plan. 13. A review of Resident number five’s (5) red folder and blue notebook revealed that the facility did not have progress notes documenting behaviors, incidents or the use of physical restraints or visitation plan or schedule with family/foster family, progress notes, treatment summaries, and treatment plan. Neither file contained contact information for the parent of Resident number five (5) with court authorized visitation. The Daily Summary for March 8, 2008 documented Resident number five (5) was on a home visit. An interview with the therapist at 2:50 p.m. on March 11, 2008 revealed that he was unaware that the contact information was not in the file. The therapist asked the shift supervisor where the contact information was located and he indicated it was on a phone sheet in the staff office. The shift supervisor was also unable to explain why it was not in the red folder or blue notebook. 14. A review of Resident number one’s (1) red folder and blue notebook was not possible because they were returned to the case manager after the resident was discharged on March 4, 2008 upon turning eighteen (18). The facility did have the Daily Summary dated March 2, 2008 and March 3, 2008 that indicated the resident was on an overnight home pass. 15. An interview with the shift supervisor on March 11, 2008 at 1:00 p.m. revealed that the red folder was assembled by the provider when a new resident was admitted. The shift supervisor stated that the red folder was supposed to contain the health assessment, school records, immunization records, court orders, contact information for family and case managers, Medicaid numbers, and birth certificates. The shift supervisor stated that the blue notebook was supposed to follow the child from placement to placement and be a chronological history of the child. The shift supervisor stated that many times the blue notebook was not provided at the same time the child was admitted and that as a result he had difficulty getting the physical examination completed timely. The shift supervisor confirmed that the red folder and blue notebook were the only clinical records he was aware of for each resident. The shift supervisor confirmed that not all of the red folders contained all of the required information. The shift supervisor also stated that progress notes were not written on each resident. The shift supervisor stated that the direct care staff completed a behavior scale and a shift report for each resident daily. When asked where the behavior scale and shift reports were kept, the shift supervisor stated that the behavior scales were maintained in a separate binder and that the shift reports were sent to the company headquarters on a weekly basis for billing purposes. 16. A review of the behavior scale revealed that all residents were maintained on the same scale. The form was set up as a spreadsheet with behaviors listed in a column on the left side and resident initials across the top in separate columns. Direct care staff used check marks to indicate the behaviors exhibited by each resident during the day. If a resident was at school or out of the facility on a home pass that was indicated by writing an "s" or "hp" in the column. The shift supervisor stated that the 7:00 a.m.-3:00 p.m. shift used the form to indicate behaviors before the residents left for school. The 3:00 p.m.-11:00 p.m. shift utilized the scale more than the other shifts. The binder contained several months worth of behavior scales. The shift supervisor confirmed that staff did not write a corresponding note in the clinical record of the resident and stated that the only records they had were the red folder and blue notebook. The facility still had the shift reports for the week of March 2, 2008. On the shift reports staff documented if the resident completed his/her chores, any problems and any education/training provided to residents. The shift supervisor confirmed that the shift reports were being sent to headquarters for billing purposes. The shift supervisor did not know what happened with them after they were sent to headquarters. 17. An interview with the program coordinator at 4:15 p.m. on March 11, 2008 revealed that he was aware the files were not complete. The program coordinator asked what he was supposed to do when the placement agencies did not provide all of the required information. The program coordinator confirmed that the shift reports were sent to headquarters for billing purposes and that he thought they were archived at that point. When asked if there was another file for each resident with progress notes, documentation related to physical restraint use, and contact information for parents the program coordinator did not respond. 18. The Respondent’s actions and/or inactions constituted a violation of Rule 65E- 9.006(12)(b) and (c), Florida Administrative Code. 19. The Agency cited the Respondent for a violation of Rule 65E-9.006(12)(b) and (c), Florida Administrative Code. 20. The Respondent was given a mandatory correction date of April 1, 2008. 21. On or about May 7, 2008, the Agency conducted a Follow-Up Survey to the Complaint Investigation (#2008002968) of March 11, 2008 of the Respondent’s facility. 22. Based on record review and interview, the facility failed to ensure that the individual record for each resident contained the required items for one (1) of three (3) sampled residents currently residing in the facility, Resident number one (1). 23. A review of Resident number one’s (1) record revealed that the resident was admitted to the facility on March 13, 2008. A review of the record revealed no documentation of treatment plans. An interview with the therapist on May 7, 2008 at 2:00 p.m., revealed that he had not completed a treatment plan for Resident number one (1). 24. The Respondent’s actions and/or inactions constituted a violation of Rule 65E- 9.006(12)(b), Florida Administrative Code. 25. The Respondent’s violation constitutes an uncorrected violation as provided by law. 26. Pursuant to Florida law, in accordance with Part II of Chapter 408, Florida Statutes, the Agency may impose an administrative penalty of no more than $500.00 per day against any licensee that violates any rule adopted pursuant to Section 394, Florida Statutes, and may suspend or revoke the license or deny the renewal application of such licensee. In imposing such penalty, the Agency shall consider the severity of the violation, actions taken by the licensee to correct the violation, and previous violations by the licensee. Section 394.879(4), Florida Statutes (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, _ intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 394.879(4), Florida Statutes (2007). COUNT I The Respondent Failed To Ensure A Complete Admission Package Was Obtained For Residents Upon Admission In Violation Of Rule 65E-9.008(7), Florida Administrative Code 27. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 28. Pursuant to Florida law, the provider shall require documentation in the child’s admission packet, including: (a) The child’s parent or guardian has given expressed and informed consent to treatment; (b) A funding source has been secured for the expected duration of the treatment. If the Department of Children and Families is the funding source, there shall be written authorization from the Department of Children and Families mental health program office that approved the . funding; (c) The admission packet shall request the identification of a discharge placement for the child upon their completion of treatment and the identification of a contact person who will participate in treatment and discharge planning; (d) The location of the parent or legal guardian or court ordered custodian with responsibility for medical and dental care, including consent for medical and surgical care and treatment and a statement signed by the parent or legal guardian, and a copy given to the parent or legal guardian, requiring the parent or legal guardian to notify the provider of any change in the parent’s or legal guardian’s address or telephone number; (e) Order of court commitment or a voluntary placement agreement with parents, guardian, or legal custodian; (f) Arrangements for family participation in the program, including phone calls and visits with the child; (g) Arrangements for clothing and allowances; (h) Arrangements regarding the child leaving the facility with or without the clinical director’s consent; (i) Written policies specifying the child’s rights as defined in Rule 65E-9.012, Florida Administrative Code; (j) Written acknowledgment of receipt and understanding by the parent or legal guardian and guardian ad litem of the provider’s policy regarding the use of restraint or seclusion during an emergency safety situation; (k) Psychiatric and psychological evaluations with diagnosis and prior treatment history and psychosocial evaluations, including family relationships, legal status and prior placement history; (1) Educational evaluation, including current individual education plan and school placement; and (m) Medical information, including a listing of current medications: 1. If a physical examination was not performed within the ninety (90) days: prior to admission and documentation of such examination was not provided, a physical examination by a licensed physician shall be initiated within twenty-four (24) hours of admission; 2. The child's medical history; 3. Written consent from the child's parent or guardian for the provider to authorize routine medical and dental procedures for the child, and to authorize emergency procedures when written parental consent cannot be obtained; and 4. Immunization status and completion according to the U.S. Public Health Service Advisory Committee on Immunization Practices and the Committee on Control of Infectious Diseases of the American Academy of Pediatrics. Rule 65E-9.008(7), Florida Administrative Code. 29. On or about March 11, 2008 the Agency conducted a Complaint Investigation (#2008002968) of the Respondent’s facility. | 30. Based on record review and interview, the facility failed to obtain a complete admission packet for four (4) of five (5) sampled residents at the time of admission, Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5). 10 31. A review of the red folder and blue notebook for Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5) revealed that each admission packet was incomplete. Resident number two’s (2), Resident number three’s (3), Resident number four’s (4), and Resident number five’s (5) records did not contain documentation signed by the parent or legal guardian indicating that all changes in contact information, address and phone number were to be provided to the facility, arrangements for family participation in the program that included phone calls and visits, and signed acknowledgment of the restraint policy. An interview with the program coordinator at 4:15 p.m. on March 11, 2008 revealed that the case managers did not always provide the facility with a completed admission packet. The program coordinator had no reply when asked what the facility did in those cases. 32. The Respondent’s actions and/or inactions constituted a violation of Rule 65E-9.008(7), Florida Administrative Code. 33. The Agency cited the Respondent for a violation of Rule 65E-9.008(7), Florida Administrative Code. 34. The Respondent was given a mandatory correction date of April 1, 2008. 35. On or about May 7, 2008, the Agency conducted a Follow-Up Survey to the Complaint Investigation (42008002968) of March 11, 2008 of the Respondent’s facility. 36. Based on record review and interview, the facility failed to have all required admission documentation in the records of two (2) of three (3) sampled residents, Resident number two (2), and Resident number three (3). 37. A review of Resident number two’s (2) record revealed that the resident had been admitted to the facility on December 10, 2007. A review of the record revealed no documentation of: 11 38. Informed consent to treatment. A funding source. Discharge placement identification. The location of the parent or legal guardian or court ordered custodian. Consent for medical and surgical care. A statement requiring the parent or legal guardian to notify the provider of any change in address or telephone number. An order of court commitment or voluntary placement. Arrangements for family participation. Asrangements for clothing and allowances. Arrangements regarding the child leaving the facility with or without the clinical director's consent. A written acknowledgement of receipt and understanding by the parent or legal guardian and guardian ad litem of the provider's policy regarding the use of restraint during an emergency safety situation. A written consent from the child's parent or guardian for the provider to authorize routine medical and dental procedures for the child and to authorize emergency procedures when written parental consent cannot be obtained. A review of Resident number three’s (3) record revealed that the resident had been admitted to the facility on December 27, 2007. A review of the record revealed no documentation of: Informed consent to treatment. A funding source. 12 39. Discharge placement identification. The location of the parent or legal guardian or court ordered custodian. Consent for medical and surgical care. A statement requiring the parent or legal guardian to notify the provider of any change in address or telephone number. An order of court commitment or voluntary placement. Arrangements for family participation. Arrangements for clothing and allowances. Arrangements regarding the child leaving the facility with or without the clinical director's consent. A written acknowledgement of receipt and understanding by the parent or legal guardian and guardian ad litem of the provider's policy regarding the use of restraint during an emergency safety situation. A written consent from the child's parent or guardian for the provider to authorize routine medical and dental procedures for the child and to authorize emergency procedures when written parental consent cannot be obtained. An interview with the program coordinator and the therapist on May 7, 2008 at 2:00 p.m. revealed that the admission paperwork is sent to the child's case manager for completion and is not always returned promptly. 40. The Respondent’s actions and/or inactions constituted a violation of Rule 65E-9.008(7), Florida Administrative Code. 41. 42. The Respondent’s violation constitutes an uncorrected violation as provided by law. Pursuant to Florida law, in accordance with Part Il of Chapter 408, Florida Statutes, the 13 Agency may impose an administrative penalty of no more than $500.00 per day against any licensee that violates any rule adopted pursuant to Section 394, Florida Statutes, and may suspend or revoke the license or deny the renewal application of such licensee. In imposing such penalty, the Agency shall consider the severity of the violation, actions taken by the licensee to correct the violation, and previous violations by the licensee. Section 394.879(4), Florida Statutes (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 394.879(4), Florida Statutes (2007). COUNT DI The Respondent Failed To Ensure That There Was Documentation That Each Family, Guardian Or Guardian Ad Litem Signed An Acknowledgement At Admission Concerning The Use Of Restraints In Violation Of Rule 65E-9.013(6)(a), Florida Administrative Code 43. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 44, Pursuant to Florida law, at admission, the provider shall: 1. Explain and provide a written copy of the provider’s procedures regarding the use of restraint and seclusion to the child, the child’s parent or guardian, and guardian ad litem, if applicable. The provider shall document that the child and the parent or guardian, and guardian ad litem were informed of the provider’s policies on the use of restraint and seclusion. This documentation shall be filed in the child’s record. 2. Communicate the procedures in a language the child and the parent or guardian understand, including American Sign Language or through an interpreter or translator if needed. 3. Include in the procedures contact information, including phone number and mailing address, of the Advocacy Center for Persons with Disabilities, Inc. 4. Consult with the child’s parent or guardian and foster parent and guardian ad litem, if 14 applicable to determine if there are any known physical or psychological risks that would rule out the use of such interventions for the child. The results of such interview shall be documented in the child’s record. Rule 6SE-9.013(6)(a), Florida Administrative Code. 45. On or about March 11, 2008 the Agency conducted a Complaint Investigation (#2008002968) of the Respondent’s facility. 46. Based on record review and interview, the facility failed to.ensure that there was documentation that each family, guardian or guardian ad litem signed an acknowledgment about the use of restraints at admission for four (4) of five (5) sampled residents, Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5). 47. A review of the red folder and blue notebook for Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5) failed to locate a signed acknowledgment by the family, guardian or guardian ad litem related to the use of restraints in the facility. An interview with the program coordinator at 4:15 p.m. on March 11, 2008 revealed that placement agencies did not always provide a complete admission packet or placement agreement to the facility. 48. The Respondent’s actions and/or inactions constituted a violation of Rule 65E- 9.013(6)(a), Florida Administrative Code. 49. The Agency cited the Respondent for a violation of Rule 65E-9.013(6)(a), Florida Administrative Code. 50. The Respondent was given a mandatory correction date of April 1, 2008. 51. On or about May 7, 2008, the Agency conducted a Follow-Up Survey to the Complaint Investigation (42008002968) of March 11, 2008 of the Respondent’s facility. 52. Based on record review and interview, the facility failed to ensure that there was documentation that each family, guardian or guardian ad litem signed an acknowledgment about 15 the use of restraints at admission for three (3) of three (3) sampled residents, Resident number one (1), Resident number two (2), and Resident number three (3). 53. A review of the resident records for Resident number one (1), Resident number two (2), and Resident number three (3) revealed no documentation of a signed acknowledgement by the family, guardian or guardian as litem related to the use of restraints in the facility. An interview with the program coordinator and the therapist on May 8, 2008 at 2:00 p.m. confirmed that this information had not been provided at the time of admission and had not been provided as of May 7, 2008. 54. | The Respondent’s actions and/or inactions constituted a violation of Rule 65E- 9.013(6)(a), Florida Administrative Code. 55. The Respondent’s violation constitutes an uncorrected violation as provided by law. 56. Pursuant to Florida law, in accordance with Part II of Chapter 408, Florida Statutes, the Agency may impose an administrative penalty of no more than $500.00 per day against any licensee that violates any rule adopted pursuant to Section 394, Florida Statutes, and may suspend or revoke the license or deny the renewal application of such licensee. In imposing such penalty, the Agency shall consider the severity of the violation, actions taken by the licensee to correct the violation, and previous violations by the licensee. Section 394.879(4), Florida Statutes (2007). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 394.879(4), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief: 16 1. Enter findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of ONE THOUSAND FIVE HUNDRED DOLLARS ($1,500.00). 3. Order any other relief that the Court deems just and appropriate. Respectfully submitted this lat day of Aucguak , 2008. fad Daley appa Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE 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 AND DELIVERED TO THE - ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING 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 BY THE AGENCY. 17 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to: David L. Ferguson, Administrator, Alternate Family Care, Inc. d/b/a Pinewood Group Home, 4055 Pinewood Road, Melbourne, Florida 32935 by U.S. Certified Mail, Return Receipt No. 7007 1490 0004 1620 7558 and to Ronald St. Simon, Registered Agent for Alternate Family Care, Inc. d/b/a Pinewood Group Home, 10540 La Reina Road, Delray Beach, Florida 33446-2725, by U.S. Certified Mail, Return Receipt No. 7007 1490 0004 1620 7565, on this wet day of Dseguscil , 2008. Lav Aine eae Assistant General Counsel Copies furnished to: Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel _ 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 David L. Ferguson, Administrator Alternate Family Care Inc. d/b/a Pinewood Group Home 4055 Pinewood Road Melbourne, Florida 32935 (U.S. Certified Mail) Mary Daley Jacobs, Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 | Cnteroffice Mail) Ronald St. Simon, Registered Agent for Alternate Family Care, Inc. d/b/a Pinewood Group Home 10540 La Reina Road Delray Beach, Florida 33446-2725 (U.S. Certified Mail) Joel Libby, Field Office Manager Agency for Health Care Administration Hurston South Tower 400 W. Robinson, Suite $309 Orlando, Florida 32801 .S. Mail) 18

Docket for Case No: 08-005175