STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Petitioner,
V, AHCA No. 2011009966
GRAND COURT VILLAGE, INC., d/b/a GRAND COURT VILLAGE I,
Respondent.
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ADMINISTRATIVE COMPLAINT
COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration ("the Agency"), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Grand Court Village, Inc., d/b/a Grand Court Village I ("the Respondent"), pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and alleges:
NATURE OF THE ACTION
This is an action to revoke the Respondent's license to operate an assisted living facility and to impose an administrative fine of$5,000.00.
PARTIES
I. 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 II, Ch. 429, Part I, Fla. Stat. (2011); 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. (2011). 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. (2011).
. The Respondent was issued a license by the Agency to operate an assisted living facility located at 295 SW 4th Avenue, Pompano Beach, Florida 33060 ("the Facility"), and was at all times material required to comply with the applicable statutes and rules governing assisted living 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 independently. 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.
COUNT!
False Representation of a Material Fact in a License Application
Under Florida law, in addition to the grounds provided in 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: False representation of a material fact in the license application or omission of any material fact from the application. § 408.815(l)(a), Fla. Stat. (2010).
On March 25, 2011, the Respondent submitted a license renewal application to the Agency with respect to the Facility. Exhibit A.
In the renewal application, the Facility Administrator swore or affirmed "under penalty of perjury, that the statements in this application are true and correct."
2
Outstanding Fines
In Section 6 of the Respondent's renewal application, the Facility Administrator answered "no" to the following question:
Pursuant to subsection 408.83l(l)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a licensee which shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment plan is approved by the agency.
Are there any incidences of outstanding fines, liens, or overpayments as described above?
Contrary to the Respondent's answer, the Respondent actually had two unpaid final orders in the amounts of $2,900.00 and $4,500.00.
The Respondent's answer to this question was false.
The Respondent's false answer misrepresented a material fact to the Agency.
The Agency relied upon the Respondent's false answer in making its decision to issue the Respondent its renewal license.
Background Screening Requirements
In Section 8 of the Respondent's renewal application, the Facility Administrator made the following attestation:
As administrator or authorized representative of the above named provider/ facility, I hereby attest that all employees required by law to under Level 2 background screening have met the minimum standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.) or are awaiting screening results. In addition, I attest that all employees subject to Level 2 screening have attested to meeting the requirements for qualifying for employment and agree to inform me immediately if convicted of the disqualifying offenses while employed here as specified in subsection 435.04(5), F.S.
Exhibit A, Section 8.
Along with the renewal application, the Respondent submitted an Affidavit of
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Compliance with Level 2 Background Screening for Covered Employees. Exhibit Bi
In the above-referenced Affidavit of Compliance with Level 2 Background Screening for Covered Employees, the Administrator made the same attestation as set forth in Section 8 of the license renewal application.
Along with the renewal application, the Respondent submitted an Assisted Living Facility (ALF) Background Screening Affidavit of Compliance. Exhibit C.
In the above-referenced Assisted Living Facility (ALF) Background Screening Affidavit of Compliance, Mr. Godinez attested under the penalty of perjury that he was in current compliance with the background screening requirements of Chapter 435, Florida Statutes, for both the Level 1 and Level 2 screenings.
Upon further review, it turns out that the Facility's Owner and Chief Financial Officer, Arturo Godinez, is disqualified from said employment in an assisted living facility.
i7. Mr. Godinez was classified by the Agency as "not eligible" at the time the license
renewal application was submitted to the Agency.
The Respondent provided the Agency sworn or affirmed statements attesting to Mr. Godinez being in compliance with the requirements of the background screening.
The Respondent's sworn or affirmed statements in its license renewal application and supporting documents were false.
The Respondent's false sworn or affirmed statements misrepresented a material fact to the Agency.
The Agency relied upon the Respondent's sworn or affirmed false statements in making its decision to issue the Respondent its renewal license.
1 The Respondent submitted tbe same "Affidavit of Compliance with Level 2 Background Screening for Covered Employees" for both Graod Court Village I and Grand Court Village II.
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WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a final order revoking the Respondent's license to operate this assisted living facility.
COUNT II
Criminal Background Screening
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 a facility. Every resident of a
. facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. § 429.28(l)(a), Fla. Stat. (2011).
Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(l)(e) pursuant to Chapter 435 and Section 408.809. § 429.174,Fla. Stat. (2011).
Under Florida law, level 2 background screening pursuant to Chapter 435 must be conducted through the Agency on each of the following persons, who are considered employees for the purposes of conducting screening under Chapter 435: (a) The licensee, if an individual.
The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the Agency has reason to believe that such person has been convicted of any offense prohibited by Section 435.04. For each controlling·interest who has been convicted of any such offense, the licensee shall submit to the Agency a description and explanation of the conviction at the time f license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal
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property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor?s employer or the licensee. § 408.809(1), Fla. Stat. (2011).
Under Florida law, every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under Chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the Agency shall request the Department of Law Enforcement to forward the person's fingerprints to the Federal Bureau of Investigation for a national criminal history record check. If the fingerprints of such a person are not retained by the Department of Law Enforcement under Section 943.05(2)(g), the person must file a complete set of fingerprints with the Agency and the Agency shall forward the fingerprints to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints may be retained by the Department of Law Enforcement under Section 943.05(2)(g). The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. Proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Agency, the Department of Health, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under Chapter 651 satisfies the requirements of this section if the person subject to screening has not been unemployed for more
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than 90 days and such proof is accompanied, under penalty of perjury, by an affidavit of compliance with the provisions of Chapter 435 and this section using forms provided by the Agency. § 408.809(2), Fla. Stat. (2011).
Under Florida law, in addition to the offenses listed in Section 435.04, all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of noio contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the offenses listed in Section 408.809(4). § 408.809(4), Fla. Stat. (2011).
Under Florida law, if an employer or Agency has reasonable cause to believe that grounds exist for the denial or tennination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. § 435.06(1), Fla. Stat. (2011).
Under Florida law, an employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the Agency as provided under Section 435.07. If an
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employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. The employer must tetminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the. employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to Section 435.07. § 435.06(2), Fla. Stat. (2011) (emphasis supplied).
Under Florida law, any employee who refuses to cooperate in such screening or
refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. § 435.06(3), Fla. Stat. (2011).
Level 2 Background Screening Requirements
Florida has one of the largest vulnerable populations in the country, with over 25% of the state's population over the age of 65, as well as children and disabled adults. These vulnerable populations require special care as they are at an increased risk of abuse. In 1995, the Florida Legislature created standard procedures for the screening of prospective employees where the Legislature had determined it necessary to conduct criminal history background checks to protect vulnerable persons. Chapter 435, Florida Statutes, outlines the background screening standards for Level 1 employment screening and Level 2 employment screening.
In 2010, the Florida Legislature substantially rewrote the requirements and procedures for criminal background screening of the persons and business that deal primarily with vulnerable populations. The 2010 changes provided that "vulnerable persons" include
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minors and adults whose ability to perform the normal activities of daily living new or to provide for his or her own care or protection is impaired due to a mental, emotional, long-term physical, or developmental disability or dysfunction, or brain damage, or the infirmities of aging. Among other things, the new requirements: (a) mandated that no person be allowed to begin work until the background screening was completed, (b) increased the level of background screening from Level 1 to Level 2, (c) expanded the number of disqualifying offenses for employees, and (d) prohibited exemptions from disqualification for employees until three after the completion of all
sentencm• g sanct1• 0ns.2
The primary purpose served by criminal background screening is the protection of the safety and well-being of the facility residents. As set forth above, assisted living facility residents often times consist of disabled adults and frail elders with mental and/or physical disabilities, who are at substantial risk of physical, mental and emotional abuse, medical neglect and financial exploitation. By enacting these provisions, the Florida Legislature has determined that the risk to this vulnerable population is of such significance that prospective employment be delayed until the risk is addressed through the background screening process. As a secondary purpose, background screening bolsters the public's trust in assisted living facilities and lessens the risk of potentially business ending civil liability for a facility. The commission of a crime or tort upon a resident not only has a direct impact upon the resident victim, but may also have an impact upon the fellow residents within the facility as well as the family members of the resident victim.
Factual Allegations
According to the Agency's licensure file, Mr. Godinez is currently employed at
2 The statements contained in this paragraph and the preceding paragraph is based upon statements and findings set forth within the Florida House of Representatives Staff Analysis for HB 7069. House Bill 7069 was enacted into law by the Florida Legislature effective July l, 2010. Ch. 2010-114, Laws of Fla.
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the Facility as its Chief Financial Officer.
Mr. Godinez currently has criminal charges pending against him for the offenses of racketeering, conspiracy and organized fraud.
Due to the pending charges, Mr. Godinez is disqualified from acting as a financial officer of an assisted living facility.
At all times material, the Respondent had actual knowledge of these pending charges against Mr. Godinez.
Notwithstanding actual knowledge of these pending charges, the Respondent has permitted Mr. Godinez to serve as its Chief Financial Officer.
The Respondent's actions have been ongoing since the retention of Mr. Godinez as the Chief Executive Officer and President and Chief Financial Officer to the present time.
The Respondent's actions or inactions constitute a class II violation.
Class "II" violations are those conditions or occutTences related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2011).
Sanction
Under Florida law, in addition to the grounds provided in 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: A violation of this part, authorizing statutes, or applicable rules. § 408.815(1)(c), Fla. Stat. (2010).
Under Florida law, 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.
§ 429.19(2)(b), Fla. Stat. (2011). A fine shall be levied notwithstanding the correction of the
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violation. §408.813(2)(b), Fla. Stat. (2011).
Under Florida law, unless the amount or aggregate limitation of the fine is prescribed by authorizing statutes or applicable rules, the Agency may establish criteria by 1ule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules. Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final order of the Agency and not subject to further appeal, the violator shall pay the fine plus interest at the rate specified in section 55 .03 for each day beyond the date set by the Agency for payment of the fine.
WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a final order revoking the Respondent's license to operate this assisted living facility and to impose an administrative fine of $5,000.00.
COUNT III
The Respondent Failed to Make Full Payment of an Administrative Fine
Under Florida law, in addition to any other remedies provided by law, the Agency may deny each application or suspend or revoke each license, registration, or certificate of entities regulated or licensed by it: (a) if the applicant, licensee, or a licensee subject to this part which shares a common controlling interest with the applicant has failed to pay all outstanding fines, liens, or overpayments assessed by final order of the Agency or final order of the Centers for Medicare and Medicaid Services, not subject to further appeal, unless a repayment plan is approved by the agency; or (b) for failure to comply with any repayment plan. § 408.831(1), Fla. Stat. (2011).
On February 11, 2010, the Agency entered a final order against the Respondent imposing an administrative fine in the amount of $2,900.00 in AHCA Case No. 2009008619.
Pursuant to the terms of the final order, the Respondent was required to make full
II
Respectfully submitted on this 12th day of September, 2011.
Vikram Mohan, Senior Attorney Florida Bar No. 49402
Office of the General Counsel
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3
Tallahassee, Florida 32308
Telephone 850-412-3658
Facsimile 850-921-0158
POSTING REQUIREMENT
Pursuant to Section 429.14(7), Florida Statutes, Agency notification of a license suspension or revocation, or denial of a license renewal, shall be posted and visible to the public at the facility.
NOTICE OF RIGHT TO REQUEST ADMINISTRATIVE HEARING
The Respondent is notified of 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 has the right to be represented by an attorney in this matter at its own expense. 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 llights 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) 412-3630.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights were served to: Arturo Godinez, Registered Agent, Grand Court Village, Inc. 295 SW 4th Avenue, Pompano Beach, Florida 33060, by United States Certified Mail (Receipt Request 7009 0960 0000 3708 2157) and Gwen M. Duncan, Administrator, Grand Court Village II, 459 Racetrack Road, Pompano Beach, Florida 33060, by United States Certified Mail
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(Receipt Request 7009 0960 0000 3708 4861) on this 12th day of September, 2011.
Vikram Mohan, Senior Attorney Florida Bar No. 49402
Office of the General Counsel
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3
Tallahassee, Florida 32308
Telephone 850-412-3658
Facsimile 850-921-0158
Copy:
Shaddrick Haston, Unit Manager
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CheckAmt: . .t-z;;
Application #: Ci i&"S
File#:
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'?!CA USE ONLY:
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Batch #: 1/J
(.,, '"!> ' I ,01)
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Health Care Licensing Application ASSISTED LIVING FACILITIES
Under the auihority of Chapters 408 Part II and 429 Florida Statutes (F.S.), and Chapters 59A-35 and 58A-5, Florida Administrative
. Code (F.A.C.), an application Is hereby made to operate an assisted living facility as indicated below:
l'rrNidt1r ,-, | -._ | end | wll be"1/1/dOII . | ' | . | . | ||||
Uceme # (for -1 apptlcatioos) 5899 | & change of owner,llip | National Provider Identifier (NPI) (lf applical>le) 1348301911D | Medicare # (CMS CCN) | -aicaid# | ||||||
Name of Assisted Living Center (W operated under a fictitious name, list that here) Gnmd Court Village n | ||||||||||
Street Address 459 Ra<etnck Road | ||||||||||
Pomoano Beach | .Broward | FL | 33060 | |||||||
Telephone Number (954) 942-3388 | Fax Number (954) 942-8901 | E-mail Address | Provider Website | |||||||
Malling Address or O Same as above (All mail will be sent to this address) 295 SW 4"' Avenue | ||||||||||
City Pomnano Beach | ·1 state FL | I | ||||||||
Gwen M. Duncan | (954) 942-3388 | |||||||||
Contact e-mail address or u Do not have e-mail | NOTE: By providing your e-mall addl8ss you agree to aooept e-mail COlrll8pOl1llen from the Aoeiw:;y | |||||||||
Provider/ Licensee lnfonnation
HCA,R menqed Fonn 3110-1008, Revised August 2010
A. Provider I -.,,_.. lowllltlfor tfle ,_.,living flicltlty name and #oqtlo,1.
B. .Ucens.ee tnfonnetlon - pleaM comp»te the following for | the entity | seeking to operate the ISS/fflld ttvtng | |
Licensee Name (may be same aa provider name above) Grand Court Villa"" II | Federal Employer Identification Number (EIN) 51-0443597 | ||
Mailing Address or u Same as above 295 SW 4"' Avenue | |||
Pomnano Beach | FL | 33060 | |
TelephOne Number 954--942-3388 | Fax Number 954-942 901 | E-mail Address | |
Description of Licensee (check one): . For Profit 181 Corporation O Limited Liabillly Company 0 Partnership □0 Individual Other | Nottor Profit 0 Corporation 0 Religious Affiliation 0 Limited Liability Company 0 Other | Public 0 State 0 City/County 0 Hospital District | |
DRAFT MAR 2 6 211,, DRAFT
Application Typ: l'h of Beds and F
DRAFT
Indicate the type of application with an 'X•. Applicatlona will not be processed if all applicable fees are not incluc:ted. All fees are
nonrefundable. Renewal and Change of Ownership applications must be received 60 days prior to the expiration Of the license or the proposed effective date of the change of ownership to avoid a late fine.
JYPE OF APPLICATION
D Initial Licensure
Was this entity previously licensed as an Assisted Living F.acility in Florida? YES D NO D
If yes, please provide the name of the agency ( different), the EIN # and the year the prior license expired or closed:
NAME: I EIN # I Year Expired/Closed:
C8l Renewal Licensure
D Change of Ownership Proposed Effective Date:
0 Change during licensure period Proposed Effective Date:
0 Add Specialty License
0 Increase/Decrease in number of licensed beds (see Section 2E)
0 Facility Name Change Proposed Effective Date:
0 Other: (please specify) _. _
TYPE OF LICENSE
Standard
0 Limited Mental Health (LMH)
0 Limited Nursing Services (LNS) Extended Congregate Care (ECC)
If applying for an LNS or ECC license, has the facility maintained a standard license for the past two calendar years, or since Initially licensed licensed less than two years? YES O NO (STOP - You are not eligible; please skip to Section C)
If applying for an LNS or ECC license, has the facility been sanctioned during the past two calendar years? 0 YES NO If applying for an ECC license, list the total number of ECC beds nsquested: 80
Identify the building, wing, floor, and rooms designated for ECC services: QQ!.n1!1
If applying for a LMH license, does the facility currently hold a Standard license and have no uncorrected deficiencies?
0 YES ONO
NUMBER OF BEDS
Please enter the Number of Beds (cumml/y licensed or proposed for inifial applicants):
NOTE: To roquost an lncreawdectesse in the number of beds pleas& - S6clion 2E. Do not include the increaseldecroase number of beds in this
count..
OSS Beds: Jl + Private Pay Beds: 1IJ! = Total Beds (OSSandPrivatePay8-J:80
Number of LNS Beds (ff 8PfJ/icBbl9J: _
Number of ECC Beds (ff applicablo): 1IJ!
,. .. ,.
.A..HCA Recommended Fom, 3110-1008, Revised August 2010
Section 59A-35.060{1), Flori<la Adminiatralive Code
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o. LICENSURE FEE •If this application is only to request an increase or decrease in the number of licensed beds (not for an initial, renewal or change of ownership) please skip to section 2D.
Ac,tion | Fee | TOTAL FEEs | |||
LICENSE FEE Standard ALF (inltial, Renewal and Cha111J8 of Ownership): O License Fee Exemption (County or Munlclpal Government pu'lflf.f!<o, 429.07151 F.S,I= S 0.00 . | $61.00 per private pay bed x l!l!number of beds+ $366.00 (not to exceed $13,443.00) 'lilf.oo + $1o.oo per bed x fil!# of beds | $ 5246.00 | |||
Specialty License - Extended Congregate Care (ECC) | J,, _ | ... 1 | $ 1315.00 | ||
Specialty License - Limited Nursing Seniice (LNS) | ..,,, . | /j . ( | i -00 +$10.00 per bed x | # of beds | $ |
Specialty License - Um'rted Mental Health (LMH) | l.f.~y••lraJ &n,,;.: | Byat,- | NO EXTRA FEE | $-0- | |
Change During Utensure Period/Replacement License •vflt L | It | $ 25.00 | $ | ||
TOTAL FEES INCLUDED WITH APPLICATION: | $ 6561.00 | ||||
P111ase mal<e check or money order payable lo the Agency for HNllh C.ra Admlnlslrallon (AHCA) | |||||
INCREASE/DECREASE IN BED CAPACITY - If requesting an increase or decrease in the current number of licensed beds (not for an initial, renewal or change of ownership) please complete this section.
Total number of currentiy licensed beds: --. Total number of beds to be D Increased or D Decreased:
Type<if&eck | ·.• lriCI... | tOec.111iad | Ucerilafee | TOTAL FEES |
Private Pay Beds | $61.00 per private pay bed x number of new beds | $ | ||
OSS Beds | No fee required for inc,ease of beds. $25.00 fee to change license | $ 0.00 | ||
LNS Beds | $10.00 psr bed x # of beds | $ | ||
LMH Beds | No fee required for inc,ease of beds. $25.00 fee to charige license | $0.00 | ||
ECC Beds | $10.00 per bed X -- # of beds | $ | ||
TOTAL for SECTION D | $ | |||
,,,_.make check or money order payable lo the.Agency for Health C.1& Admlnlslmion (AHCA) | ||||
ADD A SPECIALTY BETWEEN LICENSE RENEWAL PERIOD- If the facility currently holds a Standard licemre, and this application is to add an LNS or ECC specialty licensa between biennial license renewal periods:
Action | Fee | TOTAL FEES |
Specialty License • Extended Congregate Care {ECC) . | $515.00+$10.00perbed x #ofbeds (foo is prorated st $21.46 per month x the# of monl/Js IHlli the llcen88 exoites + $10.00 - | $ |
Specialty License - LimHed Nursing Service (LNS) | $304.00+$10.00perbed x # ofbeds (foo is pro,ated st 12.66 per month x the # ofmonths until the lic&ns& exnints + $10.00 -·. ,. | $ |
Specialty License - Limited Mental Health (LMH) | No fee required for inc,ease of beds. $25.00 fee to chanaelioense | $0.00 |
TOTAL for SECllON E | $ | |
,.,_.mal<e check or money order payable lo the Agency for Health Ca1& Admlnistlatlon (AHCA) | ||
,., ...
.A..HCA Recommended Form 3110-1006, Revised August 2010
Sectlon_591\-35.060J1),..Florida Administrative CO<le
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AUTtlORITY: '''6f'lt L s
Pursuant to section 40B.B06(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and Social Security number of the applicant and each controlling Interest, tt the applicant or controlling interest is an individual; and the name address, and federal employer identification number (EIN) of the applicant and each controlling interest, tt the applicant or controlling lntereslis not an Individual. Dlsdosure of SOcial Security number(&) is mandato,y. The Agency for Health Care Adnninlstration shall use sueh information for purposes of securing the proper identification of persons listed on this application for licansure. However in an effort toprotect all personal Information, do not include Soctal Security numbera on this form. All Soclal Security numbera muat be entered on the HeaHh Care Ucanslng Appllcatlon Addendum, AHCA Form 3110-1024.
DEFINITIONS:
Controlling Interests, as defined in subsection 408.803(7), Florida Statutes, are the applicant or licensee; a person or entity that . serves as an officer of, Is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee· or a person or entity that serves as an officer of, Is on the board of directors of, or has a 5-percent or greater ownership lnteres1in the' management company or other entity, related or unrelated, With which the applicant or licensee contracts to manage the provider. The term does not Include a voluntary board. member.
Volunta,y Board Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or officer of a not-for-profit corporalion or organization who serves solely In a volunta,y capacity, does not receive any remuneration for his or her services on the board of di.rectors, and has no financial interest in the corporation or organization.
In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest In the licensee. Attach additional. sheets if necessa,y.
Individual and/or Entity Ownership of Licensee
FUI..L NAME of IHDMDUAI. or ElflTIY | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | EIH (No SSlta) | % HIP INTEREST |
Arturo Godinez | 459 Racetrack Road, Pompano Beach | 954-942-3388 | 50% | |
Ortando BenHez | 459 Racetrack Road, Pompano Beach | 954-942-3388 | 50% | |
Board Members and Officers of Licensee
TITLE | FUU.NAME | ' PERSONAL OR BUSINESS ADORESS | TELEPHONE IIUIIBER | % OWNERSHIP INTEREST |
Director/CEO | Arturo Godinez | 459 Racetrack Road, Pompano Beach | 305-491-7300 | 50% |
President | Arturo Godinez | 459 Racetrack Road, Pompano Beach | 305-491-7300 | |
Vlce President | Orlando Benitez | 459 Racetrack Road, Pompano Beach | 305-710-4454 | 50% |
Secretary | Orlando Benitez | 459 Racetrack Road, Pompano Beach | 305-710-4454 | |
Treasurer | Orlando Benitez | 459 Racetrack Road, Pompano Beach | 305-710-4454 |
AHCA Recommended Form 3110-1008, Revised August 2010
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Section 59A-35.060(1), Florida Administrative Code
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DRATT DRAFT DRAFT
Qther:
c. Voluntary Board Members and Officers of Licensee
If the licensee is a not-for-profit corporation/organization, provide the requested information for each Individual that -rves as a voluntary board member. Attach addltional sheets if necessary.
FULLNAIIE 1/'fi;;. PERSONAL OR BUSINESS ADDRESS . | TELEPHONE NUM8ER | |
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D. Administration
1TTLE | NAME | TEI.EHPONE NUMBER | |
Adminis1Jator1Managing Emnlnvee | Gwen M. Duncan | 954-942-3388 | ...iuncan - m |
Chief Financial Officer | Arturo Godinez | 305-491-7300 |
Management Company Controlling Interests
Does a company other than the licensee manage the licensed provider?
If 181 NO, skip to section 5 - Required Disclosute.
If O YES, provide the following information:
Name of Management Company I EIN (No SSNs) | Telephone Number I Fax |
Street Address J E-mail Address City I County State I Zip | |
Mailing Address or□Same as above | |
City . State I Zip | |
I | |
Contact Person Contact E-mail | Contact Telephone Number |
In Sections A and B below, provide the Information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach addltlonal sheets if necessary.
Individual and/or Entity Ownership of Management Company
CA_R mmended f'orm 3110-1008, Revised August 2010
I IHPMFUDLULANLAoM, EEdNTITY I·. PERSONAL.OR BUSINESS ADDRESS I
I
NUMBER
EIN
(HoSSNs)
'II.OWNERSHIP
INTEREST
DRAFT
DRAFT
Board Members and Officers of Management Company
DRAFT
"JlTlE | FULL NAME | PER80NAL OR BUSINESS ,ADDRESS | TELEPffONE NUMBER | %0WNER8H1p INTI:REST |
Director/CEO | ||||
President | ||||
Vice Presilent | ||||
Secretary | ||||
Treasurer | ||||
Other: |
Voluntary Board Members and Officers of Management Company
If the management company is a not-for-profit corporation/organization, provide the requested information for each individual that
serves asa voluntary board member. Attach additional sheets if necessary.
FULLNAIIE | OR BUSINESS ADDRESS | TELEPHONE NUMBER |
Required Disclosure
The following disclosures are required:
Pursuant to subsection 408.809(1)(d), F.S., the applicant shall submit to the agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(5), F.S., for each controlling inlerest.
Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to
subsection 408.809(1)(d), Florida Statutes? (These offenses are listed on the Affidavit of Compljance with Background Sgeening Requirements. AHCA Fenn #3100-0008.) YES O NO 181
If yes, enclose the following information:
D The full legal name of the individual and the position held
DA description/explanation of the conviction(s) • If the individual has received an exemption from disqualification for the offense, include a copy
A HCA..Re,,.commended Fomi 3110-1008, Revised August 2010
.. Section_59A-35.060J1), Florida dministrative Code
purauant to section 408.810(2), F.S must provide a description and explanation of any exclusions, suspensions or tenninations from the Medicare, Medicaic:j, or I Clinical Laboratory Improvement Amendment (CUA) programs. '
Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, tenminatect or involuntarily
withclnl'Ml from partici tion in Medicare or Medicaid in any state? YES O NO 181
If yes, enclose lhe following information:
0 The full legal name of the individual and the position held
0 A descripti()flfexplanation of the exclusion, suspension, termination or involuntary withdrawal.
c. purauant to section 408.815(4), F.S., does the applicant or any oontrolling interest in an applicant have any of the following:
YES O | NO 181 | Convicted of, or entered a plea of guilty or nolo oontendere to, regardless of adjudication, a felony under chapter 409, clnapter 817, clnapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, within the previous 15 years prior to the date of this application; |
YES D | NO 181 | Terminated for cause from the Florida Medicaid program pursuant to s. 409.913, and not been in good standing withlhe Florida Medicaid program for the most recent 5 years; |
YES D | NO 181 | Terminated for cause, pursuant to the appeals procedures established by the state or federal government, from the federal Medicare program or from any other state Medicaid program, have not been In good stanctlng with a state Medicaid program or the federal Medicare program for the most recent 5 years and the tenmination was less than 20 years prior to the date of this application. |
Provider Fines and Financial Information
Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant. licensee, or a licensee whlcln shares a common oontrolling interest with the applicant if they have failed to pay aH outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment planIs approved by the agency.
Are there any incidences of outstanding fines, liens or overpayments as described above? YES D
If yes, please oomplele the following for eacln incidence (attacln additional sheets Hnecessary): Amount: $ . assessed by: 0 Agency for Health Care Administration Case#
Date of rela.ted inspeclion, application or overpayment period if applicable: Due date of payment:
NO 181
0 CMS
Is there an appeal pending from a Final Order? YES 0 NO D
Please attach a copy of the approved repayment plan ff applicable.
Other Program Specific Information
Please provide the following information for the requested positions:
Does the owner, administrator, or any facility representative serve as 'representative payee• or as power of attorney for any ALF residents? 0 YES 181 NO · .
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HCA_R mended Fom, 3110--1008, Revised August 2010 Section 59A-35.060(1), Flonda Administrative Code
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DRAFT J DRAFT . } DRAFT .
-•"'"'•Pa)IWf i8 an Individual or en1ify who recetvea oo bellall ofa resident Q.e. soda\ security benefila, &t.lS>Plernenta180<:ial
oroptiailal-lUIJl)lot,iontalkln).
payeeor powe. of attorney;
give ccnstmlfof an-•or fadlily to act as their
If yes, section 429.27(2), F.S., states that you !!ll!!! obtain a surety bond or continuum bond from a licensed surety company. Has
a surety or continuum bond been obtained? 0 YES O NO Please attach a copy.
"
· Is the ALF a part of a continuing care retirement community (CCRC) pursuant to Chapter 651, F.S.? 0 YES 121 NO
If yes, attach a copy of your Certificate of Authority with the inltial or change of ownership application.
" b
c.· Does the ALF participate in a Medicaid Waiver prwram·f
number: 686184900 ff,4,9
8.
Affidavit¾;;',J , II,,.,,,,,
,;";' :,,I I <01,
O NO lfyas, please provide your Medicaid
I, Gw n M DLl:!lra t\ , hereby swear or affirm, under penalty of perjury, that the statements in this application are true and correct. As administrator or authorized representative of the above named provider/facility, I hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum
standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.) or are awaiting screening results.
In addition, I attest that all employees subject to Level 2 screening standards have attested to meeting the requirements for qualifying for employment and agree to inform me immediately if convicted of any of the disqualifying offenses while employed here as specified in subsection 435.04(5), F.S.
RETURN THIS COMPLETED FORM WITH FEES ANO ALL REQUIRED
. DOCUIIEHTS TO:
AGENCY FOR HEALTH CARE ADMINISTRATION
ASSISTED LMNG UNIT
'.i.7Z7 MAHAN DR., MS 30
TALlAHASSEE FL 32308-5407
Que911ons? R8'lieW the infolmation available at httpJlahca.myftorida.cqm/
or oontact lhe Assisted Living UnA at (850) 412-4304
Signature of Licensee or Authorized Representative
aJ,.,lt<1,$trq_"Q r-
Trtle
.A..HCA..Re,_eommanded Fomi 3110-100B, Revised August 2010
Section-59J\-35.060J1)•.Florida ministrative Code
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IIAR2 5 2011.
MCaennatgrie1,,s, Ystems
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Affidavit of Compliance with Level 2 Background Screening
for Covered Employees
Authority: Pursuant to_ subsection 435.05(3), Florida Statutes (F.S.), each administrator or similarly titled person who Is responsible for the day-to-day operation of the provider must sign an affidavit annually, under penalty of perjury, stating that all employees required 16 undergo Leve\ 2 screening have been scree8ed or are newly hired and are awaiting the results of \he required screening checks. This includes the financial officer or individual who is responsible for the financial operation of_the licensee or provider. ·
In a_ddi\ion, pursuant to subsection 435.04(5), F.S., the administrator must attest annually, under penally of perjury, that all employees subject to Level 2 screenirg standards have attested to meeting the requirements fol qualifying for employment and agree to Inform the employer Immediately If convicted of any of the disqualifying offenses while employed by the employer.
Grand Court Village II AL5899
P_rovider/F cility Name
459 Racetrack_ Road·
Street Address
AHCA License Number
Pompano· Bea_ch | FL | 3 3 0 6□· {954} 942-6000 | |
City | State | Zip | Telephone Number_ |
As administrator'of the above named provider/facifity, I hereby attest that all employees required by law to undergo Level 2 backgrolrnd screenllig have met the niininnum standards of section 4'35.04, Florida Statutes (F.S.),'or are awaiting screening results.
In addition, :1 attest U1at all employees ubject to Level 2 screening sta dards have attested to meeting the requirements for qualifying for employment and agree to inform me Immediately if
· ¼ .-,
. convicted of any of the disqualifying offenses while employed here as specified in s bsection . 4 ),F.S. .
Administrator
Signature Title
STATE OF FLORIDA
COUNTY OF 13 fOl.iJ O,.,\.c.)
Sworn to and subscribed before me this \ day of {\; ,
This Individual is personally known to me or produced the following identification: _
SANDRA P MARRERO MY COMMISSION# 0D515'858 EXPIRES: M r. 6, 2010
Notary Public NOTARY SEAL:
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AHCA Form #3100-0067, November 2006
·Page1 of1
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Attachment B
ASSISTED LMNG FACILITY (ALF) BACKGROUND SCREENING AFFIDAVIT OF COMJ>LIANCE
SECTION 400.4174, FLORIDA STATUTES
Underpenaltyofperjury,I, Arturo Godin.ez dohereby
(Print Name)
certify thatl currently comply with the background screening requirements of Chapter 435, Florida Statutes, for (please check the appropriate box):
[ X] Level ! Screening
[X) Level 2 Screening -
. (S'ignature) (Date)
. STATE OF FLORIDA
COUNTY OF
BEFORE ME, the undersigned authority, A'ttiuu:, bo :Z
personally appeared, and after first being duly sworn in, did depose and say that he/she did . execute the foregoing Assisted Living Facility Background Sc,reening Affidavit of Compliance
and that the same is true, accurate and correct to the best of his/her knowledge, information and belief ·
SWORN TO AND SUBSCRIBED before me this· day of )'.'W:O:'.':'J , 200_:t
NOTARY PUBLIC
My commission expiresi Personally known / or Produced identification
Type of identification produced _
Postaye $
Cerf/fled Fee
Postmark
Here
Retum Receipt Fee (Endorsement Required)
Resfrfcfed Dellvery Fee (Erxlorsement Required)
Total Postage & Fees $
Complete items i ,·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 mailplece, or on the front if space permits.
Article Addressed to:
nt ;
jg Addressee i
Is delivery address different from item 1? D Yes
If YES, enter delivery address be/ow: D No
e lype
□Certified Mall O Express Mall .
t0'
Registered □ Return Receipt for Merchandise
O Insured Mail □ C.O.D.
Restricted Delivery? (Extra Fee) □ Yes
2. 7009 0960 0000 3708 3451
PS Form 3811, February 2004 Domestic Return Receipt
Postage
$:
7
CertUled Fee
1---------1
Return Receipt Fee
(Endorsement Required) 1 \
1-------\
Restricted Del1Ve1y Fee (Endorsement Requlred)
Total Postage & Fees L.:$ -----
Poslmark
Here
| e D. Is dellve If YES, enter detlvety address below: |
1. Artlde Addressed to: | |
|
L
I
1 2
· 7009 0960 0000 3708 :157
I PS Form 3811, February 2004 Domestic Return Receipt 102595,P2·M·1540
or on the front If space permits. | ||
1--------'----'----------1 1. Article Addressed to: | 1O, Is delivery address different fromItem 17 Yes If YES, enter delivery address below: □No | |
| ||
2. 7009 0960 DODD 3708 3451 | ||
Postage $ 1
Certltled Fee
(Endorsemenl Required) " <
Reslrlcled Dellve,y Fee
{Endorsement Aequlred) ' '
Total Postage & Fees $,: ,
Heturn Receipt Fee
Postmatl<
Here
\ PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M•1540 ,
| B. Received by |
D. ls delivery a If YES, enter delivery address below: | |
1. Article Addressed to:
| |
3. elype l!1" Certified Mall D Express Mall 0 Registered D Return Receipt for Merchandise D Insured Mall 0 0,0.D. 4, Restricted Delivery? (Extra Fee) □ Yes |
Postmark
He,e
., .
2. 7009 0960 DODD 3708 2157
PS Form 3811, Februal)' 2004 Domestic Return Receipt 102595-02-M-1540
