STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR. HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2011010009 GRAND COURT VILLAGE, INC., d/b/a GRAND COURT VILLAGE II, Respondent. / 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 II (“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 1. 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 Il, 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 Filed October 24, 2011 11:35 AM Division of Administrative Hearings may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (201 1). 2, The Respondent was issued a license by the Agency to operate an assisted living facility located at 459 Racetrack Road, Pompano Beach, Florida 33060 (“the Facility”), and was at all times material required to comply with the applicable statutes and rules goveming 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, COUNTI False Representation of a Material Fact in a License Application 3, 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(1)(a), Fla. Stat. (2010). 4, On March 25, 2011, the Respondent submitted a license renewal application to the Agency with respect to the F acility. Exhibit A. 5S. In the renewal application, the Facility Administrator swore or affirmed “under penalty of perjury, that the statements in this application are true and correct.” Outstanding Fines 6. In Section 6 of the Respondent’s renewal application, the Facility Administrator answered “no” to the following question: Pursuant to subsection 408.831(1)(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? 7. Contrary to the Respondent’s answer, a sister assisted living facility, Grand Court Village I, in which the Respondent shares a common controlling interest, actually had two unpaid final orders in the amounts of $2,900.00 and $4,500.00. 8. The Respondent’s answer to this question was false. 9. ‘The Respondent’s false answer misrepresented a material fact to the Agency. 10. The Agency relied upon the Respondent’s false answer in making its decision to | issue the Respondent its renewal license. Background Screening Requirements 11. 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. 12, Along with the renewal application, the Respondent submitted an Affidavit of Compliance with Level 2 Background Screening for Covered Employees, Exhibit B.! 13. 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. 14. — Along with the renewal application, the Respondent submitted an Assisted Living Facility (ALF) Background Screening Affidavit of Compliance. Exhibit C, 15. 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. 16. 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. 17. Mr. Godinez was classified by the Agency as “not eligible” at the time the license renewal application was submitted to the Agency. 18. The Respondent provided the Agency sworn or affirmed statements attesting to Mr. Godinez being in compliance with the requirements of the background screening. 19. The Respondent’s sworn or affirmed statements in its license renewal application and supporting documents were false. 20. The Respondent’s false sworn or affirmed statements misrepresented a material fact to the Agency. 21. The Agency relied upon the Respondent’s sworn or affirmed false statements in * The Respondent submitted the same “Affidavit of Compliance with Level 2 Background Screening for Covered Employees” for both Grand Court Village I and Grand Court Village I. 4 making its decision to issue the Respondent its renewal license. 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 22, 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(1)(a), Fla, Stat. (201 1). 23. Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(1)(e) pursuant to Chapter 435 and Section 408.809. § 429.174, Fla. Stat. (2011). | 24. — 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. (b) 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 he 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 of icense 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 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). 25. 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 5 requirements of this section if the person subject to screening has not been unemployed for more 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). 26. 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 nolo 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. (201 1). 27. Under Florida law, if an employer or Agency has reasonable cause to believe that grounds exist for the denial or termination 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). 28. 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 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 terminate 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), 29. 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 30. 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, 31. 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 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 sentencing sanctions,” 32. 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, * 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 1, 2010. Ch. 2010-114, Laws of Fla. Factual Allegations 33, According to the Agency’s licensure file, Mr. Godinez is currently employed at the Facility as its Chief Financial Officer. 34, Mr. Godinez currently has criminal charges pending against him for the offenses of racketeering, conspiracy and organized fraud. 35. Due to the pending charges, Mr. Godinez is disqualified from acting as a financial officer of an assisted living facility, 36. At all times material, the Respondent had actual knowledge of these pending charges against Mr. Godinez. 37, Notwithstanding actual knowledge of these pending charges, the Respondent has permitted Mr. Godinez to serve as its Chief Financial Officer. 38. The Respondent’s actions have been ongoing since the retention of Mr. Godinez . as the Chief Financial Officer to the present time. 39. The Respondent’s actions or inactions constitute a class II violation. 40. Class “II” violations are those conditions or occurrences 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, of security of the clients, other than class J violations. § 408.813(2)(b), Fla. Stat. (2011), Sanction 41. 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). 42. Under Florida law, the Agency shall impose an administrative fine for a cited class ITI 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 violation. § 408.813(2)(b), Fla. Stat, (2011). 43. 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 rule 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 It A Licensee In Which The Respondent Shares a Controlling Interest Fajled to Make Full Payment of an Administrative Fine 44. 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). 45. The Respondent shares a common controlling interest with a sister assisted living facility, Grand Court Village, Inc., d/b/a Grand Court Village I (“Sister Facility”). 46. The Sister Facility was issued a licensee by the Agency and was a licensee at the time of the entry of the final orders 47. The Sister Facility is currently licensed as an assisted living facility in Florida. 48. On February 11, 2010, the Agency entered a final order against the Sister Facility imposing an administrative fine in the amount of $2,900.00 in AHCA Case No. 2009008619, 49. Pursuant to the terms of the final order, the Sister Facility was required to make full payment of the administrative fine within 30 days of the entry of the final order, 50. As of this date, the Sister Facility has not tendered full payment to the Agency with respect to the final order and the amount due remains outstanding. 51. On November 2, 2010, the Agency entered a final order against the Sister Facility imposing an administrative fine in the amount of $4,500.00 in AHCA Case No. 2009004030, 52. Pursuant to the terms of the final order, the Sister Facility was required to make full payment of the administrative fine within 30 days of the entry of the final order. 53. As of this date, the Sister Facility has not tendered full payment to the Agency with respect to the final order and the amount due remains outstanding. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license to operate this assisted living facility, CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief against the Respondent as set forth above. 12 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 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) 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 Il, 459 Racetrack Road, Pompano Beach, Florida 33060, by United States Certified Mail B (Receipt Request 7009 0960 0000 3708 4861) on this 12th day of September, 2011. Copy: Shaddrick Haston, Unit Manager 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 14 EC, DRAFT 4 Mp “WVegeart a tray Ky oN “Benton Mt FLORIDIA AGENCY FOR HEALTHCARE ADMINISTRATION B25 Health Care Licensing Application a. ASSISTED LIVING FACILITIES Under the authority of Chapters 408 Part Il and 429 Florida Statutes (F.S.), and Chapters 594-35 and 584-5, Florida Administrative Code (FA.C.), an application is hereby made to operate an assisted living facility as indicated below: 1. Provider / Licensee Information Provider Informati Provid Licersse # (for renewal & change of owners application) 5464 Name of Assisted Living Center (if operated under a fictitious name, list that here) Grand Court Village I Street Address 295 SW 4 Avenue Gity Zip Pompano Beach 33060 Telephone Number Fax Number E-mail Address Provider Website (954) 942-6000 (954) 942.8901 gduncan@grandcp.com www.grandcp.com Mailing Address or Dd] Same as above (All mail will be sent to this address) Contact Person for this application Contact Telephone Number Gwen M. Duncan, Administrator 954) $42-6000 Contact e-mail address or [.] Do not have e-mail NOTE: By providing your it address you agree to a t e-mail gduncan@grandcp.com B, Licensee Information -— facility. Licensee Name (may be same as provider name above) Federal Employer Identification Number (EIN) Grand Court Village | 51-0443597 ne Address or Same as above City | State Zip [Teens Number Fax Number E-mail Address (954) 942-6000 (954) 942-8901 gduncan@grandep.com Description of Licensee (check one): For Profit Not for Profit Public & Corporation { t Corporation UJ State (2 Limited Liability Company LJ Religious Affiliation U City/County Q Partnership OO Limited Liability Company (J Hospital District 0 individual 1D Other O01 Other , AHCA Recommended Form 3110-1008, Revised August 2010 ; Section 59A-35.060(1), Florida Administrative Code aA x A. DRAFT . j DRAFT REC... Vep DRAFT MAR 9 5 204 2. Application Type, Number of Beds and Fees Con LAS yeep pm Magement Un le Indicate the type of application with an “X." Applications will not be processed if all applicable fees are not included. Aly 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 fate fine. A. TYPEOF APPLICATION (71 initial Licensure Was this entity previously licensed as an Assisted Living Facility in Florida? YES (J no (J If yes, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed: NAME: ] EIN# Year Expired/Closed: {Renewal Licensure [1 Change of Ownership Proposed Effective Date: CI Change during licensure period Proposed Effective Date: a [J Add Specialty License [1] Increase/Decrease in number of licensed beds (see Section 2E) (0 Facility Name Change Proposed Effective Date: CJ Other: (please specify) ee B. TYPE OF LICENSE & Standard C1 Limited Nursing Services (LNS) (1 Limited Mental Health (LMH) C] 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 if licensed less than two years? . O yes 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? ([] YES O No If applying for an ECC license, list the total number of ECC beds requested: Identify the building, wing, floor, and rooms designated for ECC services: If applying for a LMH ticense, does the facility currently hold a Standard license and have no uncorrected deficiencies? Olyes [no OT C. NUMBER OF BEDS Please enter the Number of Beds (currently licensed or proposed for initial applicants): NOTE: To request an increase/decrease in the number of beds please see Section 2E. Do not include the increase/decrease number of beds in this count. OSS Beds: 40 + Private Pay Beds: 85 = Total Beds (OSS and Private Pay Beds): 425 Number of LNS Beds (if applicable): ‘ Number of ECC Beds (if applicable): _ AHCA Recommended Form 3110-1008, Revised August 2010 Section 59A-35.060(1), Florida Administrative Code DRAFT / DRAFT DRAFT D. LICENSURE FEES - {f this application is only to request an increase or decrease in the number of licensed beds (not for an initial, renqwal or change of ownership) please skip to section 2D. Action Fee TOTAL FEES $61.00 per private pay bed x 85 number of $°5551.00 beds + $366.00 (not to exceed $13,443.00) . LICENSE FEE Standard ALF (intial, Renewal and Change of Ownership) (J License Fee Exemption (County or Municipal Goverment p t to 42917(5), F.S.)= $0.00 Specialty License - Extended Congregate Care (ECC) ” Specially License - Limited Nursing Service (LNS) . é §.00 + $10.00 perbed x ss #ofbeds =| $ $304.00 + $10.00 per bed x # ofbeds | $ NO EXTRA FEE | $-0- Spécialty License - Limited Mental Health (LMH) Mangal Sys Change During Licensure Period/Replacement License ne Uni $ 25.00 | ¢ $ TOTAL FEES INCLUDED WITH APPLICATION: 5551.00 [ Please make check or money order payable to the Agency for Health Care Administration (AHCA) E, 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 currently licensed beds: Total number of beds tobe [[] increased or [) Decreased: License Foe Private Pay Beds $61.00 per private pay bed x number of new beds OSS Beds | No fee required for increase of beds. $25.00 fee to change license LNS Beds $10.00 per bed x # of beds LMH Beds No fee required for increase of beds. $25.00 fee to change license ECC Beds $10.00 per bed x # of beds TOTAL for SECTION D | §$ Please make check or money order payable to the Agency for Health Care Administration (AHCA) F. ADD A SPECIALTY BETWEEN LICENSE RENEWAL PERIOD - If the facility currently holds a Standard license, and this application is to add an LNS or ECC specialty license between biennial license renewal periods: . Action Fee TOTAL FEES $515.00 + $10.00 per bed x # of beds Speciaity License - Extended Congregate Care (ECC) (fee is prorated at $21.46 per month x the # of months until the license expires + $10.00 per bed $304.00 + $10.00 per bed x # of beds Specialty License - Limited Nursing Service (LNS) (feo is prorated at 12.66 per month x the # of months until the license expires + $10.00 per bed) Specialty License — Limited Mental Health (LMH) No fee required for increase of beds. $25.00 fee to $0.00 change license TOTAL for SECTION E |'$ Please make check or money order Payable to the Agency for Health Care Administration {AHCA) AHCA Recommended Form 3110-1008, Revised August 2010 Section 59A-35.060(1), Florida Administrative Code a VED a DRAFT MAR 9 5 ny DRAFT DRAFT t Marta opi 3. Controlling Interests of Ltensee A eA Tere AUTHORITY: Purstuanlto section 408,806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and Social Securitynumber of the applicant and each controlling interest, if 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, if the applicant or controlling interest |s not an individual. Disclosure of Social Security number(s) is mandatory. The Agency for Health Care Administration shalt use such information for purposes of securing the proper identification of persons listed on this application for licensure. However, in an effort to protect all personal information, do not Include Social Security numbers on this form, All Social Security numbers must be enteid on the Health Care Licensing Application Addendum, AHCA Form 3110-1024. te 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 interest in 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. Voluntary Board Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or officer of a not-for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, 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 6% or greater ownership interest in the licensee, Attach additional sheets if necessary. . A. Individual and/or Entity Ownership of Licensee FULL NANE. of INDIVIDUAL or. PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER (to SSN) OQWNERSHIP ____ ENTITY; a : INTEREST Arturo Godinez 295 SW 4th Avenue, Pompano Beach (954) 942-6000 50% Orlando Benitez 295 SW 4% Avenue, Pompano Beach (954) 942-6000 : 50% B. Board Members and Officers of Licensee TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE. NUMBER OWNERSHIP | : : INTEREST Directov/CEO | Arturo Godinez 295 SW 4 Avenue, Pompano Beach (305) 491-7300 50% President Arturo Godinez 295 SW 4% Avenue, Pompano Beach (305) 491-7300 Mee sent Orlando Benitez 295 SW 44 Avenue, Pompano Beach (305) 710-4454 50% | Secretary Onlando Benitez (305) 710-4454 Treasurer | Orlando Benitez + (305) 7 10-4454 AHCA Recommended Fonn 3110-1008, Revised August 2010 . Section 59A-35.060(1), Florida Administrative Code “FVED y DRAFT MAp 9 f DRAFT DRAFT | Other: - i nage oY Stom 8 C. ‘Voluntary Board Members dip fficers of Licensee Ifthe licensee 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. FULL NAME PERSONAL OR BUSINESS ADDRESS [ TELEPHONE NUMBER — —L a D. Administration TLE ; TELEHPONE ere NAME ; NUMBER E-MAIL. Administrator/Managing . Employee Gwen M. Duncan 954-942-6000 duncan@grandcp.com Chief Financial Officer Arturo Godinez 305-491-7300 agodinez@grandcp.com 4. Management Company Controlling interests Does a Company other than the licensee manage the licensed provider? If KX] NO, skip to section 5 ~ Required Disclosure. if [1] YES, provide the following information: Name of Management Company EIN (No SSNs) Telephone Number / Fax Street Address E-mail Address City [son |” Mailing Address or (-]Same as above City State Zip Contact Person Contact E-mail Contact Telephone Number in Sections A and B betow, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary. A. Individual andor Entity Ownership of Management Company FULL NAME of EIN % OWNERSHIP {No SSNs) _ INTEREST INDIVIDUAL of ENTITY PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | AHCA Recommended Form 3110-1008, Revised August 2010 Section 59A-35.060(1), Florida Administrative Code DRAFT , DRAFT B. Board Members and Officers of Management Company [me Fol wae DirectorCEO President Vice President ere —_ a TELEPHONE ‘% OWNERSHIP PERSONAL OR BUSINESS ADDRESS NUMBER INTEREST i Treasurer [ Other: C. 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 a8 a voluntary board member. Attach additional sheets if necessary. PERSONAL OR BUSINESS ADDRESS . TELEPHONE NUMBER LT LL SSN OR et Arrests Sane naneereret 5 . Required Disclosure The following disclosures are required: A. Pursuant to subsection 408.809(1)(d), F.S., the applicant shail 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 interest. 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 Compliance with Background Screening Requirements, AHCA Form #3100-0008.) YES [] NO kd Ifyes, enclose the following information: () The fult 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 AHCA Recommended Form 3110-1008, Revised August 2010 ; Section 59A-35.060(1), Florida Administrative Code DRAFT DRAFT : DRAFT a . B, FPunuant to section 408.810(2), F.S., the Yasrcant must provide a description and explanation of any exclusions, suspensions, or temninations from the Medicare, Medicaid, or federal Clinical Laboratory !mprovement Amendment (CLIA) programs. Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withdravn from participation in Medicare or Medicaid in any state? Yes O NO If yes, enciose the following information: (] The futt fegal name of the individual and the position held OA description/explanation of the exclusion, suspension, termination or involuntary withdrawal. C. Pursuant to section 408.81 5(4), F.S., does the applicant or any Controlling interest in an applicant have any of the following: YES] NOB Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss, 1395-13896, within the previous 15 years prior to the date of this application; YES] NOB Terminated for cause from the Florida Medicaid program pursuant to 8. 409.913, and not been In good standing with the Florida Medicaid program for the most recent 5 years; YESC] NO® 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 standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination was less than 20 years prior to the date of this application. 6. 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 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? YES oO NO & If yes, please complete the following for each incidence (attach additional sheets if necessary): Amount: $ assessed by: [7] Agency for Health Care Administration Case # —_—. C] cms Date of related inspection, application or overpayment period if applicable: —__ Due date of payment: Is there an appeal pending from a Final Order? YES NO &) Please attach a copy of the approved repayment plan if applicable. 7. Other Program Specific Information Please provide the following information for the tequested positions: A. Does the owner, administrator, or any facility representative serve as “representative payee" or as power of attomey for any ALF residents? [J] YES & NO AHCA Recommended Form 3110-1008, Revisad August 2010 Section 59A-35.060(1), Florida Administrative Code 5 a By a 3 : DRAFT DRAFT DRAFT Exgrotentative Payee is an individual or entty who receives payments on behalf of a resident (ie. social security benefits, | social S-6tr'lty or optional state supplementation). A resident must give consent for an owner, administrator or facility representative to: act as their representative payee of power of attomey. - If yos, section 429.27(2), F.S., states that you must obtain a surety bond or continuum bond from a licensed surety company. Has @ Siety or continuum bond been obtained? YES [J] NO Please attach a copy. B. {s the ALF a part of a continuing care retirement community (CCRC) pursuant to Chapter 651, F.S.2, [] YES ®& No if yés, attach a copy of your Certificate of Authority with the initial or change of ownership application. C. Does the ALF participate in a Medicaid REO, ? [] YES §&NO If yes, please provide your Medicaid number: VE Map » 5 . G, eon 8. Affidavit Mage, YSton, , Gwen M Dunca ay , 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, | 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; | 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.- Title Signature of Licerlsee or Authorized Representative Date RETURN THIS COMPLETED FORM WITH FEES AND ALL REQUIRED DOCUMENTS TO: AGENCY FOR HEALTH CARE ADMINISTRATION g ASSISTED LIVING UNIT 2727 MAHAN DR., MS 30 TALLAHASSEE FL 32308-5407 Questions? Review the information available at: http /ahca. myftorida. cony fj oF contact the Assisted Living Unit at (850) 412-4304 AHCA Recommended Form 3110-1008, Revised August 2010 Section 59A-35.060(1), Florida Administrative Cade Affidavit of Compliance with Level 2 Background Screening for Covered Employees FLORIDA AGENCY FOR HEAITH CARE ADMINGTRATION - 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 t6 undergo Level 2 screening have been screened or are newly hired and are awaiting the results of the required screening checks, This includes the financial officer or individual who is responsible for the financial operation of the licensee or provider. In addition, pursuant to subsection 435.04(5), F.S., the administrator must attest annually, under Penalty of perjury, that all employees subject to Level 2 screening standards have attésted to meeting the requirements for qualifying for employment and agree to inform the employer immediately if convicted of any of the disqualifying offenses while employed by the ernployer. Grand Court Village IT . , -ALS&94 ; : Provider/Facility Name ; ; oo AHCA License Number 454 Racetrack Road: — . - Street Address . ., ‘ Pompano Beach FL , 330b0 TA547 W4e-bOOo . City ; ; ' State Zip Telephone Number. f ’ As administrator'of the above named provider/facility, | hereby attest that all ernployees required by law to undergo Level 2 backgrotnd screening have met the minimum standards of section 435,04, Florida Statutes (F.S.), or are awaiting screening results. in addition, | attest that all employees subject fo 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 . 435.0A(5), F.S. a, . ‘Administrator Signature . Title STATE OF FLORIDA COUNTY OF_ Broward Swomn to and subscribed before me this _|@ day of a, B004, | This individual is personally known to me or produced the following identification: oq, Tanoeasvansans Na Pie a s MY COMMISSION # DD525858 ‘ 5 eee EXPIRES: Mar. 6, 2010 Cees ers : AHCA Form #3100-0007, November 2006 Form avaliable at: htto:/ahca myflorida comMCHQ/Corebllifindex.shtm! “Page { of 1 , é 2 Mgt Attachment B fang ra gy, ttachmen: men's ASSTSEED LIVING FACILITY (ALI) BACKGROUND SCREENING ; AFFIDAVIT OF COMPLIANCE. SECTION 400.4174, FLORIDA STATUTES Under penalty of perjury,I, Arturo Godinez do hereby (Print Name) certify that I 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 - Gignature) ate) STATE OF FLORIDA COUNTY OF "Bue ‘ BEFORE ME, the undersigned authority, Aylin Godsme2 personally appeared, and after first being duly swom in, did depose and say that he/she did . execute the foregoing Assisted Living Facility Background Screening 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 {Q «day of _Grlonssony 2004. NOTARY PUBLIC get, SANDRAPMARRERO. | 49 Was = MY COMMISSION # DDsisese Crops EXPIRES: Mar. 6,2010 (407) s0e-0168 Florida Notary Senvica.cot, Seren meter i~ My commission expires: 3| ey) 9610 Personally known J or Produced identification Type of identification produced KO. 3451 7005 0560 oooo 3708 ®™ Complete Item: item 4 if Restricted Delivery Cettitied Fee Postmark Return Recelpt Fee Here (Endorsement Required) Restricted Dellvary Feo ndorsement Regitlrad) Total Postage & Fees BPA Coun Aton Ain Gatracd Couk| $SA faved boach . .. nets 12 : is 1, 2, and 3. Also complete _ Sav py erase is desired, i @ Print your name and address on the reverse Addressee po So that we can return the card to you. calved by Printed Name} @ Attach this card to the back of the mailpiece, z ve , Goan Or on the front if Space permits. D. Is delivery address different from Item 1? O Yes If YES, enter delivery address below: C1 No 3. @ Type teroertine Mall O Registered 0 Insured Mail © Express Mail 7 Return Receipt for Merchandise Ocop, 102596-02-M-1540 : Certilled Fee Postmark here Return Recelpt Foe (Endorsement Required) jostticted Dalivaly Fee Ceioreeatant Required) ‘fotal Postage & Fees Pihanicy Coan ed Bary, Regn a Sirest Apt No,’ saga Gabo ooo 3708 eLse SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery Is destred, @ Print your name and address on the reverse so that we can return the card to you, § Attach this card to the back of the mailpiece, or on the front if space permits, f (1 Agent { C1) Addressee { tem 1? “Yes Wf YES, enter delivery address below: 1 No 1, Article Addressed to: \u y\ “4 \ Aw, 38 wpm Type i a SY oS AS Certified Mall [2 Express Mall ; C1 Registered O Return Receipt for Merchandise ; Vor pon Rack, FURY Vag E Cl insured Mal C1. 0.000. Restricted Delivery? (Extra Fee) (1 Yes 2, PS Form 381 1, February 2004 Domestic Return Recelpt : 102695-02-M-1540

Docket for Case No: 11-005463