Sep 24 2009 11:37 aa/2d/28e9 11:33 8589218158 PAGE @7/ld _ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2009008020 Return Receipt Requested: v. 7008 O500 0002 0764 9183 7008 0500 0002 0764 9190 A & J SUBACHAN INVESTMENT INC. d/b/a BILMAR GARDENS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against A & J Subachan Investment inc. d/b/a Bilmar Gardens (hereinafter “Bilmar Gardens”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2008), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $700.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2008), for the protection of public health, safety and welfare. Sep 24 2009 11:37 a/24/2889 11:33 85892148158 PAGE 48/14 JURISDICTION AND VENUE 2. This Court has jurisdiction pursvant to Sections 120.569 and 120.57, Florida Statutes (2008), and Chapter 28-106, Florida Administrative Code (2008). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2008). PARTIES 4, AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part: I, Florida Statutes (2008), and Chapter 58A-45 Florida Administrative Code (2008). 5. Bilmar Gardens operates a 26-bed assisted living facility located at 380 South Federal Highway, Dania, Florida 33004. Bilmar Gardens is licensed as an assisted living facility under license number 5836. Bilmar Gardens was at all times material hereto a licensed facility under the licensing authority of AKCA and was required to comply with all applicable rules and statutes. Sep 24 2009 11:38 aa/2d/28e9 11:33 8589218158 PAGE @g/1d4 COUNT I BILMAR GARDENS FAILED TO MAINTAIN MINIMUM WEEKLY STAFF HOURS. RULE 58A-5.019(4) (a)l, FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS TII VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. Te Bilmar Gardens was cited with one (1) Class III deficiency as a resuit of complaint investigations surveys that were conducted on March 23, 2009 and April 29, 2009. 8. A complaint investigation survey was conducted on March 23, 2009. Based on observation and interview with the staff member in charge on the day of the survey at approximately 12:00 PM, it was determined that the facility failed to maintain the minimum weekly staff hours. The. findings include the following. 3. The resident census on the day of the survey was 19 residents requiring 253 staff hours per week. The written staffing schedules and time sheets maintained documented that only 233 staff hours per week are currently being maintained. 10. The current schedule being maintained revealed the facility was currently providing less than the required hours of staffing. The residents all have a mental health diagnesis and Sep 24 2009 11:38 aa/2d/28e9 11:33 8589218158 PAGE 1@/1d4 require at the minimum 24 hour supervision of their whereabouts, meals, and medications. 11. During an interview at approximately 12:30 PM, the staff member in charge acknowledged the findings. 12. The mandated date of correction was designated as April 23, 2009, 13. A complaint investigation survey was conducted on April 29, 2009. Based on observation and interview with the staff member in charge on the day of the survey at approximately 12:00 PM, it was determined that the facility failed to maintain the minimum weekly staff hours. The findings include the following. 14... The resident census on the day .of the survey was 18 residents, requiring 253 staff hours per week. The written staffing schedules and time sheets maintained documented that only 243 staff hours per week are currently being maintained. 15. The current schedule being nainteined revealed the facility was currently providing less than the required hours of staffing. The residents all have a mental health diagnosis and require at the minimum 24 hour supervision of their whereabouts, meals, and medications. 16. During an interview at approximately 12:30 PM, the staff member in charge acknowledged the findings. This is an uncorrected deficiency from the survey of March 23, 2009. Sep 24 2009 11:38 aa/2d/28e9 11:33 8589218158 PAGE 17. Based on the foregoing facts, Bilmar Gardens violated Rule 568A=5.019(4) (a)l, Florida Administrative Code, herein classified as an uncorrected Class III. violation, which warrants an assessed fine of $700.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: . 1. Enter a judgment in favor of the Agency for Health Care Administration against Bilmar Gardens on Count I. 2. Assess an administrative fine of $700.00 against Bilmar Gardens on Count I fer the violation cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2008). 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 11/14 Sep 24 2009 11:38 ao/24/2089 11:33 8589218158 PAGE 12/14 Administration, and delivered ta the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER sn Lane Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. —- Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Sep 24 2009 11:39 aa/2d/28e9 11:33 8589218158 PAGE Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Frogram Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 {Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by .U.S. Certified Mail, Return Receipt Requested to Andy Subachan, Administrator, Bilmar Gardens, 380 South Federal Highway, Dania, Florida 33004; Andy Subachan, Registered Agent, 390 .8. Federal Highway, Dania Florida 33330 on this 2b “aay of , 2009. ces Cloner ourdes A. Naranjo, Esq. 13/14 ao/24/2089 11:33 9509210158 Sep 24 2009 11:39 PAGE 14/14 COMPLETE THIS SECTION ON DELIVERY = Complete tems 1, 2, and 4. Also complete A Is) ' ip 1 Agent item 4 if Restricted Delivery is desired, lf Print your name and address on the reverse ‘ 1 Agtiresses so that we can return the card to you. ad Nama) Date very lm Attach this card to the back of the mailpiece, {or on the front If space permits. - 7 ' D. Is delivery address different from item 17? UO Yés 1. Atticle Addressed to: Eves: anter dafivery address below: C1Ne Cartitied Fea a d G echo Rietum Receipt Fe {Endorsement required Lanier) Aan cow A965 Bows Fecherall Wha Dania. Fmilles Trot Restricted Deliver (Endorsement Toaed) 3. Serice Typ? 1O Certified Mail 1 Express Mall 1 Registered C1 Return Receipt for Merchandise ; Ab, : Ol insured Malt — 1 6.0.D. Le ata ; T Rasticted Delivary? (Ext Fes) splice ths Locka | apna aso00 oo0e A?bs Aaa {Transfer from ‘service label) PS Form 3811, February 2004 Domestic Return Racelpt Cdenin Cara gaa Total Poaiage & Fees | O1 ves 7008 o500 BbGe OFb4y W1a3 rd i {02895-02-M-1540

Docket for Case No: 09-005234