STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE. OF FLORIDA,AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012000070 v. Return Receipt Requested: 7009 0080 0000 0586 5259 MYRTLE MERINA PETERSON, d/b/a PETERSON, MYRTLE MERINA (Owner/Operator) , Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA” or “Agency”), by and through the undersigned counsel, and files this administrative complaint against Myrtle Merina Peterson d/b/a Peterson, Myrtle Merina (hereinafter “Peterson, Myrtle 'Merina ”), pursuant to Chapter 429, Part II, and Section 120.60, Florida Statutes, (2011), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $500.00 pursuant to Section 429.71(1)(b), Florida Statutes (2011), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. Filed April 9, 2012 8:00 AM Division of Administrative Hearings 3. Venue lays pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4, AHCA is the regulatory authority ‘responsible for licensure and enforcement of all applicable statutes and rules governing Adult Family Care Home (AFCH) facilities, pursuant to Chapter 429, Part II, Florida Statutes (2011), and Chapter 58A- 14 Florida Administrative Code. 5. Peterson, Myrtle Merina operates a 5-bed AFCH facility located at 120 Maple Avenue, Fort Pierce, Florida 34982. Peterson, Myrtle Merina is licensed as an Adult Family Care Home facility under license number 6905990 with an expiration date of 4/26/2013. Peterson, Myrtle Merina was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT _I PETERSON, MYRTLE MERINA FAILED TO LIVE AT THE FACILITY Sections 429.63(2), 429.65(2), and 429.67(2), Florida Statutes, and/or Rule 58A-14.008(2) (a)2, Florida Administrative Code (GENERAL LICENSURE STANDARD) CLASS II DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the Operation Spot Check Appraisal visit conducted on 11/23/2011 and based on interviews, it was determined that the facility failed to ensure the provider lived in the home with residents. 8. On 11/23/2011 at 12 PM, the relief person was interviewed and stated that the provider stayed overnight at the facility "sometimes". There were limited personal belongings of the provider's in the living area where the relief person slept. Resident #1 was interviewed at 12:30 PM and stated that the provider "stops by once a week to pick up mail". Resident #2 was interviewed at 12:45 PM and stated that the provider "never spends the night here". 9. Resident #3 stated during interview at 1 PM that the provider "doesn't live here and never sleeps here". The provider arrived at the facility at 1:30 PM and stated that she did have. a condominium close by and slept there because her husband was not able to live at the facility. 10. Based on the foregoing Peterson, Myrtle Merina violated Sections 429.63(2), 429.65(2), and 429.67(2), Florida Statutes, and/or Rule 58A-14.008(2) (a)2., Florida Administrative Code, a Class II deficiency and the fine assessed is $500.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency against Peterson, Myrtle Merina on Count I. 2. Assess an administrative fine of $500.00 against Peterson, Myrtle Merina on Count I, for a violation of Chapter 58A-14, Florida Administrative Code. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that. it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2011). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Attention Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. “ Uy ria Lawton-Russel' Assistant General Counsel Agency for Health Care Administration 8333 N.W. 537% Street, $-300 Miami, Florida 33166 ¢ Copies furnished to: Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Myrtle Merina Peterson, Owner/operator, Peterson, rtle Merina,,120 Maple Avenue, Fort Pierce, Florida, 34982 on Wr525, v Tia Lawtori-Russell f SENDER: COMPLET TE THIS SECTION inplete 7. Complete’ items Atem-4 If Restricted | i Print your name an 80 that we can retu W@ Attach this card.t¢ or-on the front If sp hie reverse D, {8 nee aadiess different from item 1% Yes 1, EYES, enter delivery address below: EL.Now 4. ‘Article Addressed to: Loot hier: "Ed esorese an ~ fe for Merchandise ° 6.0.0. : ~ 2) Article Number: | (Transfer from service bl | BS.Form 3811, February 2004 Domestic Return Rocalpt

Docket for Case No: 12-001221

Orders for Case No: 12-001221