Feb. 15. 2013 11:44AM FL Builders Appliance Sarasota No. 5211 =P. 8/13 j STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR. HEALTH CARE ADMINISTRATION, Petitioner, vw AHCA No. 2012012785 DULCE HOGAR I], INC., 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, Dulce Hogar IL, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: | Le) CTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. 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 II, Ch, 429, Part J, Pla. Stat, (2011); Ch. 58A-5, Fla. Admin, Code. The Agency may deny, tevoke, 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 Cee tar EVES Pha TTT PL WULFYGIO Applause vaoragovig WU. YLII Pe Yd may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2011). 2." The Respondent was issued a license by the Agency to operate an assisted living facility located at 3601 sw 139" Ave., Miami, Florida 33175 (“the Facility”), and wag at all times material requixed to comply with the applicable statutes and rules governing assisted living facilities. Assisted living facilities are residential cave 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 altemative to the more restrictive, institutional settings for individuals who do not requie 24-hour nursing supervision. Assisted living facilities are regulated in a manner so as to encourage dignity, individuality, and choice for tesidents, while providing them a teasonable 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 Terminated For Cause From State Medicaid Program 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 bya controlling interest: «+» (¢) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid ptogrann, the Medicaid program of any other state, or the Medicare program. § 408,815(1)(e), Fla. Stat. (2012). . 4, ~ On November 5, 2012, the Agency terminated Leo Homes, Inc. for cause from the state Medicaid program by way of Final Order issued by the Agency in Case No. Cl Feb. 15. 2013 11:44AM = FL Builders Appliance Sarasota No 5211 =P. 10/13 130301000, Provider Number 006277700, 5. Leonard Sifredo is a controlling interest in Leo Homes, Inc. 6. Leonard Siftedo is a controlling interest in Dulce Hogar Il, Inc. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, . seeks the revocation of the Respondent’s license, CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to enter a final order granting the following relief: 1, Make findings of fact and conclusions of law in favor of the Agency. 2. Impose the relief against the Respondent as set forth above, Respectfully submitted on this 4" day of February, 2013. 'y Assistant General Counsel, Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, M83 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John. Bradley@ahca myflorida.com NOTICE 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, Feb. 15. 2013 11:44AM FL Builders Appliance sarasota No o2Zt) oY. LN 1S 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 | HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights were served on the persons below on this 4" day of February, 2013. . JobéE. Bradley Assistant General Counsel Florida Bar No, 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 Job, Bradley@ahca.myflorida.com Copies: [Leonor Siftedo, Administrator Shaddrick Haston, Unit Manager Dulce Hogar Il, Inc. (Electronic Mail) 3601 SW 139 Ave Miami, Florida 33175 | Certified Mail ~ 7008 1300 0000 6174 2890 4 Michael Perez, Registered Agent Dulce Hogar I], Inc. 10126 W Flagler Street Miami, Florida 33175 Certified Mail- 7008 1300 0000 6174 2883 Feb. id. 2013 14:44AM = FL Buifeers Apsiiance Sarasota . No 52tt oP 14/13 CA | . AGENCY CLERK STATE OF FLORIDA i . AGENCY FOR HEALTHCARE ADMINISTRATION 013 FEB 26 A ihe. ty _ Re: DULCE HOGAR '-, INC.. , : AHCA No, 2012012785 ELECTION OF RIGHTS ‘This Election of Rights forma is attached to a proposed agency action by the Agency for Health Care Administration (AHCA), The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint; Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk with} 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached ‘proposed agency action. If your Elevtion of Rights with your selected option is not received by ARCA within 24 days of the day that you received this proposed agency, action, you will have waived your right to-coutest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attomey or your representative prefer to reply according to Chapter]20, Floride Statutes, and. Chapter 28, Florida Administrative Code.) : Please retum your Election of Rights to this address: ‘ . Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 ; Tallahassee, Florida 32308 ' Telephone: 850-412-3630 Facsimile: 850-921-0158 | _ PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) 1 admit to the allegations of facts and Jaw contained in ‘the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I watve my right to object and to have 2 hearing, I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. ; i ’ OPTION TWO (2) _ T admit fo the allegations of facts contained in ‘the Notice of Intent to Impose a Late Fee, Notlce of Intent to Impost.a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section, 120.57(2), Florida Statutes) where 1 may submit testimony and written evidence to the Agency to show that ~ the proposed administrative action is too severe or that the fine should be reduced, : OPTION THREE (3). _ 1 dispute the allegations’ of-fact contained im the Notice of Intent to Impose a Late Pee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and 1 request 4 formal heariag (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings, maa eof - wh et aude PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written Petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. it must be received by the Agency Clerk at the addresg above within 21 davs of your receipt of this Proposed agency action. The request for formal heating must conform to the requirements of Rule 28-106,2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (ifany) of the Respondent. 2. The name, address, telephone number and facsimile number of the attomey or qualified representative of the Respondent (if any) upon whom service’ of pleadings and other papers shall made. : , . : 3. A statement requesting an administrative heating identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the adrainietwative complaint. ’ 5. A statement including the file number to the administrative conoplaint. agrees, Licensee Name: V ; Contact Person:(_“\ eo | othe Address: Mediation under Section, 120.573, Florida Statutes, may be available in this matter if the Agency - Number and Sirect Do Clty Zip Code Telepbone No, 205-3 5 ’ - Uf S00 ‘Pax No. AOS = 35K -SHN3 Bite (option CPO." Fe (la@ vitalches (law. eo a Thereby certify that f am duly authorized to submit this Election of Rights to the Agenoy for Health Care Administration on 9) of the licensee! referred to above. ; Date: 2°25 13 : Printed Name: Cyresto er i Quelle. Title: TP, C He, ¢ PC, CF (4) A Mohen Ae Qual®. Rep. willbe Bled upon jecemt oF Ni Signed: \ THE HEALTH LAW OFFICES OF my Tt ANTHONY C. VITALE, P.A, ; FACSIMILE TRANSMITTAL Slinny Sr Sanenineresemme a TO: FROM: Richard Shoop Chtistopher Patrella, JD, CHC, CPC, CPCO COMPANY: : DATE: : . . 2/26/2013 - ; FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER (850) 921-0158 : PHONE NUMBER: RE; : Dulce Hogar, Inc. Clurcent Clror xevizw Otease commenr PLEASE REPLY C] pease REcycLE rae eeneeemeeinieen ee er lr a NOT ES/COMMENTs: The petitions will be Provided to you tomorrow, February 27, 2013. Sincerely, Chris Anthony C. Vitale (ayitle(@vinnlehalthlew.com) Christopher A. Parrella (Chantella@yvitalehealthlaw.com) Peter Suarez i Ww.com) Lorena Fermandez Ofemander@Qviralehealthlaw.com) Garett W, Betancourt ghetancourt@jvitalehealthlak com) Chato Mactines (cmnastinec@vitalchealthlaucom) Aileen Calmet (4 a Ww, LAW CENTER AT BRICKELL BAY, 2343 BRICKELL AVE, SUITE A-1 | MIAMI, FL 33229 : 305-358-4500 OFEICE 305-358-5113 FAX STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2012012785 DULCE HOGAR I, INC., Respondent. . / ADMINISTRATIVE COMPLAINT ee EE 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, Dulce Hogar II, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: , NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. 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, (011). Tn 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). 2. The Respondent was issued a license by the Agency to operate an assisted living facility located at 3601 SW 139" Ave., Miami, Florida 33175 (“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 I Terminated. For Cause From State Medicaid Program 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: ... (€) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)(e), Fla. Stat. (2012). 4, On November 5, 2012, the Agency terminated Leo Homes, Inc. for cause. from the state Medicaid program by way of Final Order issued by the Agency in Case No. CI 130301000, Provider Number 006277700. 5, Leonard Sifredo is a controlling interest in Leo Homes, Inc. 6. Leonard Sifredo is a controlling interest in Dulce Hogar II, Inc. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. _ Impose the relief against the Respondent as set forth above. Respectfully submitted on this 44 day of February, 2013. Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John, Bradley@ahca.myflorida.com NOTICE 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 on the persons’ below on this 4 day of February, 2013. JobffE. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 — John. Bradley@ahca.myflorida.com Copies: Leonor Sifredo, Administrator Shaddrick Haston, Unit Manager Dulce Hogar II, Inc. (Electronic Mai!) 3601 SW 139 Ave : Miami, Florida 33175 Certified Mail — 7008 1300 0000 6174 2890 Michael Perez, Registered Agent Dulce Hogar II, Inc. 10126 W Flagler Street Miami, Florida 33175 Certified Mail- 7008 1300 0000 6174 2883 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: DULCE HOGAR II, INC. AHCA No. 2012012781 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 ; Telephone; 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) : I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing, [ understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes, It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. . The request for formal hearing must conform to the requirements of ~ Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent, 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. Astatement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter ifthe A gency agrees. Licensee Name: Contact Person: a . . Title: Address: ; . Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) [ hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: _ Title: Pood ee ¢ | se0u 2 abers04 pero, ug » ; w (bembsy wewesiopys) OO Seq Aenyeg paousey o atsH {penbou weursssopun) o Sey Wiscoy wume: ELUYSOg i] et (3 = Sex POUBIE Tr e ~ = nm: a ped ao Obs Lsw-zo-segzor ydisoey wimoy opseuiog poog Areniqes ‘| ge ued Sd . eqe] somes way sejsuey) : be 4dt4 OOF00 ooeT eboe 2equMN pay (004 BBG) Lhueaged paasay “y ‘WoO = Iewpainsu 2 sKoO ‘SSIPUEYEVy 10} drecey Wmey oO PeseysiBey - on! mnsoes reno SLIEE epLOLy Tare PAV 6E1 MS.109E ‘OU] ‘Tl es oppesng Jorensturupy “opsyigsen0a] on *mojeg ssauppe Aeayep soja ‘S34 4 20] pesseuppy epasy “| “syuuad eoeds 41 OY aly uO JO i ‘eoaidirew ety Jo Yoeq au} 0} pres siLQ Weny mE “NOK 0} preo eu} Lunes URS am JEU) OS i SSIOA21 OY} UO SSeuppe PU EWeU INOA JUL mw ; jPauseP S| Atented Peyonssy Hy wey; ayedw0o osty *g pur ‘Z ‘| sway eqaIdUIOD gy : NOILIFS SIHL FLFIGNOD “YAGNAS

Docket for Case No: 13-001837