STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2013006861 Return Receipt Requested: v. 7009 0080 0000 0585 8299 KANLAKE CORPORATION INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Kanlake Corporation Inc. (hereinafter “Kanlake Corporation Inc.”), pursuant to Chapter 429, Part I, Chapter 408, Part II, and Section 120.60, Florida Statutes (2012), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the assisted living facility license [License No.: 10609] of the Respondent and to impose an administrative fine of $21,500.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2012), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and Chapter 28-106, Florida Administrative Code (2012). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2012). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Chapter 408, Part II, Florida Statutes (2012), and Chapter 58A-5 Florida Administrative Code (2012). 5. Kanlake Corporation Inc. operates a 6-bed assisted living facility located at 308 S. 30" Street, Fort Pierce, Florida 34947. Kanlake Corporation Inc. is licensed as an assisted living facility under license number 10609. Kanlake Corporation Inc. 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. COUNTI KANLAKE CORPORATION INC. FAILED TO ENSURE APPROPRIATE AND ADEQUATE SUPERVISION IS PROVIDED TO ALL RESIDENTS. RULE 58A-5.0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE/SUPERVISION STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Kanlake Corporation Inc. was cited with deficient practice as the result of a complaint investigation survey that was conducted from June 24, 2013 through June 28, 2013. Additionally, on June 27, 2013, as a result of this survey, an Emergency Suspension Order was placed on Kanlake Corporation Inc. [AHCA No.: 2013006703]. 8: A complaint investigation survey was conducted from June 24, 2013 through June 28, 2013. Based on record review, observation, and interview, it was determined that the facility failed to ensure appropriate and adequate supervision is provided to all residents that reside at the facility. As evidenced by failure of the facility to provide supervision to prevent an alleged sexual assault of Resident #2 and by locking of the sliding glass door isolating the residents to one side of the house without means of assistance, supervision and care. The findings include the following. 9. Observation on 6/24/13 at 10:40 AM with the Assistant Administrator and Caregiver revealed Resident #2 was sitting on the couch crying under distress. Surveyor #1 asked Resident #2 what was wrong. Resident #2 revealed Resident #1 sexually assaulted her last night. Resident #2 described the assault as Resident #1 attempt "[......]" to her. Surveyor #1 immediately advised the facility to call 911 about the sexual assault allegation. 10. During an interview on 06/24/13 at 11:05 AM with the local police officer, the Case Worker, and Resident #2, Resident #2 confirmed aforementioned. It was revealed the incident happened between 10 and 11 PM the night before. Resident #2 revealed she had last taken a shower 3 days ago. Resident #2 was observed dirty and revealed she had not changed clothes since her last shower. 11. Interview at 11:13 AM with Resident #2's Case Worker revealed she has been the resident's case manager since Wednesday. She has never heard any negative allegations from her. According to the Case Worker, "she is not known for telling stories". During a confidential interview on 06/24/13 at 11:20 AM, it was revealed the facility has a problem and that the local police have been called to the facility multiple times over the years for assault allegations and elopement. 12, At 12:15 the local police department located Resident #1 at a comer store. The resident was brought back to the facility. The officer stated they found a couple of beers and a baggie with a syringe and multiple pills in his back pack. During an interview on 06/24/13 at 12:30 PM with Resident #1 and #2, both residents were observed wearing dirty clothes, both residents confirmed they had not taken a bath. Resident #1 revealed, "there is nothing to do around here so he walks around and stays out". 13. He stated "the housekeeper gave him the medicines today". Observations of the clear plastic baggie revealed 1 syringe and 9 pills inside. Resident #1 during the interview was not able to identify what medications he is currently taking and the pills were unable to be identified. He also stated he is on insulin for his diabetes and he takes his insulin himself. He does not keep track of his glucose levels. He also stated the air conditioner is not on all the time because everyone goes in and out. 14. Review of Resident #1's record with the employee #1 revealed an admission date of 11/01/12. Resident #1's health assessment (form AHCA 1823) dated 10/08/12 documented a diagnosis to include: psychotic diagnosis, schizophrenia, alcohol abuse, medical diabetes mellitus, hypertension, and total blindness in his right eye. The form documented the resident required supervision with bathing, dressing, and grooming and independent with ambulation and eating. It was noted the form was left blank under the ADL section for toileting and transfer. 15. Further review revealed the resident was identified as a limited mental health (LMH) resident in which the resident was receiving services under the facility's LMH license. The form documented the resident Page 4 of the form documented the resident needed help with medications, but does not identify medication assistance or medication administration. During an interview with Employee #1 at 12:10 PM on 06/24/ 13, she stated Resident #1 administers his own insulin. 16. Further record review revealed the file lacked documentation of a physician's order to self-administer medications. Further interview with Employee #1 revealed the facility did not have an order for Resident #1 to self-administer his insulin. 17. Review of Resident #2's file revealed an admission date of 09/01/09. Resident #2's health assessment form (form 1823) with no date, documented a diagnosis of hypertension, seizure disorder, seizure control. The form documented the resident required supervision with dressing and grooming and independent with ambulation, bath, eating, toileting, and transfer. Further review revealed the resident was identified as a limited mental health (LMH) resident in which the resident was receiving services under the facility's LMH license. 18. During an interview with employee #5 (the night shift employee/sole employee) on 06/24/13 at 11 AM, he stated that he did not hear any commotion on the evening of 06/23/13, when the alleged assault occurred. He confirmed the sliding door was closed and locked and stated "I was around". However, he was not able to provide information regarding any safety or wellness checks performed throughout the night due to the sliding door being looked and the resident's isolated to one side of the facility. 19. During an interview with the Administrator/Owner and Employee #1, both denied any prior knowledge of the alleged assault prior to the surveyor being made aware by Resident #2. Record review failed to indicate any documentation regarding this incident. 20. During a tour of the facility on 6/24/13 at 9:15 AM with the Assistant Administrator, the staffing schedule was posted on the wall. Review of the schedule revealed it was not accurate. There were at least two employees (employee #7 and #8) listed on the schedule that were no longer employed with the facility as confirmed by the Assistant Administrator. One employee that was scheduled for 9 AM was running late. The Assistant Administrator stated 17 people were currently in the facility. However, the census count changed multiple times throughout the survey as more unidentified persons appeared (in which it was later determined these individuals were residents). 21. __ It was revealed six people live here and 11 people come over daily from the other facility. They spend the day at this facility, eat all of their meals here, and return to the other licensed facility to sleep. It was also revealed by the Administrator/Owner and Employee #1 that all residents are limited mental health residents and require daily supervision. 22. During an interview at 9:45 AM on 06/24/13 with the Assistant Administrator and Employee #5 (who just entered the building and identified himself as "the night shift") also lives on site. He stated at night he works by himself and the other residents leave around 5-6 PM. They come here daily then go to their appointments. Employee #5 stated" at 7:30 PM the phone is shut off and around 8-9 PM the sliding glass door is locked so the residents do not raid the fridge. They can knock on the sliding door or they can go outside of the facility and walk around the side of the facility and knock on my window if they need something". 23. Upon further investigation of the parameter of the facility, it was noted that the residents upon exiting the facility at night are exposed to outside elements jeopardizing their safety and well-being. The facility is set up where a section of the house including the kitchen and employee living area for the night shifts room is separated from the residents by a sliding glass door. Once the door is locked the residents do not have access to the kitchen area or the night staff for any form of assistance or need. 24. An interview on 6/25/13 at 9:06 AM with employee #6 (in the kitchen), revealed she works at the other facility (the other facility owned by the Administrator) as a Med Tech. She stated they pick everyone up daily at 8 AM and take them back around 8 PM. She also stated 11 people live at other facility and they all come here. 25. During an interview on 06/24/13 at 10:00 AM an Employee #1, revealed she cooks and gives medications to all the residents at the facility. Further interview with Employee #1, revealed if the residents need assistance in the evening they can go to the window". 26. Random confidential interviews revealed there is a lack of supervision and assistance at night. All interviews revealed if there is a problem there is no staff to talk to. We just hang around doing, nothing all day. At night, if we need something, we knock on the glass door and sometimes he does not even come out, he is in the room with the door closed". 27. Further record review revealed the facility did not have permission from the local fire department to lock this additional door (exit/entrance) to ensure safety compliance. 28. The facility failure to provide adequate supervision resulted in the alleged sexual assault of Resident #2. Further review revealed residents have no means to acquire immediate help in the event of an emergency due to the locking of the sliding glass door at night. 29. Based on the foregoing facts, Kanlake Corporation Inc. violated Rule 58A- 5.0182(1), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $7,500.00 and also gives rise to the revocation of the assisted living facility license. COUNT II KANLAKE CORPORATION INC. FAILED TO ENSURE RESIDENTS HAVE ACCESS TO ADEQUATE AND APPROPRIATE HEALTH CARE CONSISTENT WITH ESTABLISHED AND RECOGNIZED STANDARDS WITHIN THE COMMUNITY. RULE 58A-5.0182(6), FLORIDA ADMINISTRATIVE CODE (RESIDENT RIGHTS/FACILITY PROCEDURES STANDARDS) CLASS I VIOLATION 30. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. A complaint investigation survey was conducted from June 24, 2013 through June 28, 2013. Based on observation, interview, and record review, it was determined that the facility failed to ensure residents have access to adequate and appropriate health care consistent with established and recognized standards within the community. In accordance with Section 429.28, Florida Statutes, have a written grievance procedure for receiving and responding to resident complaints, Residents performing work in the facility without compensation, provide residents with convenient access to a telephone to facilitate the resident's right to unrestricted and private communication, pursuant to Section 429.28(1)(d), Florida Statutes, live in a safe and decent living environment, free from abuse and neglect. Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. The findings include the following. 32. A tour of the facility on 6/24/13 with the assistant administrator at 9:15AM revealed the following: At 9:40AM, the thermostat read 90 degrees and the residents’ area smelled of urine. The surveyor noted a male changing bed linens and mopping resident rooms he was identified as the cleaning man. On 6/25/13 at approximately 10:38 AM with a second surveyor present and the facility's LPN, this same male was observed mopping resident rooms and was identified by the assistant administrator as someone who was being paid by a cleaning agency. During the interview, it came out that he is a resident from their sister facility and they are not paying for his services. The resident stated he volunteers to clean 5-6 days a week about 6 hours a day because it gives him something to do. 33. During an interview at 9:45AM with resident #2, she stated "It's hot in here. Woman's son unplugs the phone at night. They talk ugly to me. "Resident was asked who and referred to the nightshift employee. Unsampled Residents sitting outside stated, "if there is a problem nobody to talk to. We just hang around don't do nothing all day. At night if we need something, we knock on the glass door and sometimes he doesn't even come out. He's in the room with the door closed". 34. Observation at 10:33AM Outside the door off the dining area a resident was seen sleeping on the dirty ground. The resident stated she lives at the other facility and was tired. 35. Interview on 6/24/13 at 10:37 AM with an unsampled resident she stated she lives at the other facility. She was asked how things were around here and she stated "they are very controlling here. We do nothing at all. All day long". 36. A request was made to the facility LPN for the grievance log and facility grievance policy. The LPN stated they did not have a grievance log or policy. She stated when residents have a complaint they try to address it. The facility failed to demonstrate that such procedure is implemented upon receipt of a complaint. 37. The surveyor conducted a tour of the facility on 6/25/13 at approximately 10:38 am accompanied by a second surveyor and Employee #1. During the observation of Resident Room #1, the surveyor noted a male changing the bed linen. A mop and bucket were positioned by the door. The surveyor asked who if the individual was a resident or a staff member. The resident stated that he is a volunteer and cleans the facility 6 hours a day 7 days a week. The Surveyor asked the Manager if the individual was an employee or a resident. She stated that he was not an employee and that he was paid by a cleaning company. When asked if the facility pays the cleaning company, the Manager denied this also. The Manager also stated that the same individual was not a resident. She stated that he doesn't live here, he sleeps somewhere else. 38. At approximately 2:00 PM, the Surveyor asked Employee to provide a list of the residents who resided in the facility and the 10 residents who came to the facility from the sister facility. She stated that she did not have a list but could provide their names from memory. She stated that there were a total of 6 residents who resided in the facility in accordance with the license for 6 residents and an additional 10 residents who are brought over from the sister facility and return in the evening for a total of 16 residents housed at the facility during the day. 10 39. After reviewing the 16 names, the surveyor noted that the individual who was observed mopping the floors and making beds was actually a resident from the sister facility. The Manager was asked again if Resident #14 was a resident and she confirmed that he was a resident at the sister facility and was not compensated by the facility for his labors as required by regulations. 40. Additional scrutiny was conducted of the resident names provided by the facility and the names provided by residents who had been interviewed. The surveyor determined that the name of Resident #17 was not identified by Employee #1 as residing in either facility. When this information was discussed with Employee #1 she stated that Resident # 17 actually residents at the facility, which would confirm that 7 residents reside at the facility which is licensed for 6. The Employee confirmed that the facility has more residents than their license allows. 41. During an interview at 9:45 AM on 06/24/13 with the Assistant Administrator and Employee #5 (who just entered the building and identified himself as "the night shift ") also lives on site. He stated at night he works by himself and the other residents leave around 5-6 PM. They come here daily then go to their appointments. Employee #5 state "at 7:30 PM the phone is shut off and around 8-9 PM and the sliding glass door is locked so the residents do not raid the fridge. They can knock on the sliding door or they can go outside of the facility and walk around the side of the facility and knock on my window if they need something". 42. Upon further investigation of the parameter of the facility, it was noted that the residents upon exiting the facility at night are exposed to outside elements jeopardizing their safety and well-being. The facility is set up where a section of the house including the kitchen and employee living area for the night shifts room is separated from the residents by a sliding glass door. Once the door is locked the residents do not have access to the kitchen area or the 11 night staff for any form of assistance or need. It was noted that the facility restricts access to phone in violation of the resident bill of rights. 43. Based on the foregoing facts, Kanlake Corporation Inc. violated Rule 58A- 5.0182(6), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $6,000.00 and also gives rise to the revocation of the assisted living facility ° license. COUNT II KANLAKE CORPORATION INC. FAILED TO ENSURE THAT STAFF OBSERVED RESIDENTS TAKING MEDICATION. RULE 58A-5.0185(3), FLORIDA ADMINISTRATIVE CODE (MEDICATION ASSISTANCE STANDARDS) CLASS II VIOLATION 44. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 45. A complaint investigation survey was conducted from June 24, 2013 through June 28, 2013. Based on record review and interviews, it was determined that the facility failed to ensure that facility staff observed residents taking medications and that if they gave the residents medications to take when they left the facility that they understood what they were taking for 1 out of 3 sampled residents (Resident #1) The findings include the following. 46. A review of the Medication Administration Record (MAR) and the Physician Orders for Resident #1 revealed that he had orders for the following medications to be administered at 8:00 PM: On the MORs in the space used to document the administration of pills 12 administered on 5/24/13 at 8:00 PM, was a white substance covering documentation in ink for the following medications: 47. When asked, the Manager, Employce #1 stated that the staff gave Resident #1's evening medications because he was not coming back to the facility that evening. She stated that the facility did not have a medication policy, but staff are required to physically observe the resident consume their medications. She could not explain why the medicine technician did not document that she gave the evening medications to the resident or why she used white out on the MAR. 48. She confirmed that the staff should never put white out on the MORs and/or the resident's record. She stated that the resident should have been provided the following medications upon notification to staff that he was leaving and would not return for his evening medications: The staff would then document on the MORs by each dose of medication that was provided to the resident. The following medications should have been provided to the resident and were covered by white out on the MORs: a) Benztropine 2 mg (1 pill). b) Divalproex (Depakote) 500 mg (2 pills of 250 mg each). c) Metformin 500 mg (1 pill). d) Urea cream. e) Novolin 70/30 Insulin 50 units sub cutaneous injection. f) Total 4 pills, 1 tube of urea cream and an Insulin filled syringe. 49. On 06/24/13, Resident was located by Law Enforcement and returned to the facility that afternoon. He had a plastic bag containing 8 pills and a syringe in his pockets. When asked what the pills were or what they were for, the resident stated that he did not know and he 13 was given the medications by Employee # 2 who is the facility cook. Employee # 1 was asked if the resident is aware of what his medications are for and she stated he must have been confused because he knows them. When asked why the resident had double the number of pills he should have been given, she did not reply. 50. The facility failed to ensure assistance with self-administered medications was provided to Resident #1 directly threatens the safety and well-being of the resident. 51. Based on the foregoing facts, Kanlake Corporation Inc. violated Rule 58A- 5.0185(3), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $2,500.00 and also gives rise to the revocation of the assisted living facility license. COUNT IV KANLAKE CORPORATION INC. FAILED TO ENSURE FINANCIAL STABILITY AS EVIDENCE BY A DELINQUENT UTILITY BILL OF TWO (2) MONTHS. RULE 58A-5.021(1), FLORIDA ADMINISTRATIVE CODE (FISCAL/FINANCIAL STABILITY STANDARDS) CLASS IIT VIOLATION 52. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 53. A complaint investigation survey was conducted from June 24, 2013 through June 28, 2013. Based on record review and interview, it was determined that the facility failed to ensure financial stability as evidenced by having a delinquent utility bill for 2 months and failure to repair the central conditioning unit. The findings include the following. 14 54. A request was made on 6/25/13 to the Owner/Administrator and Employee #1 for the last 3 months of income and expense statements, bank statements, mortgage payments, and utility bills. The utility bill dated 6/17/13 showed a past due balance of $545.17 and a current balance of $538/12 due 06/28/13. 55. The facility is also the representative payee for the residents and was not able to provide evidence of accounting procedures. The owner/administrator and LPN acknowledged the findings. The owner also stated she keeps the facility money and the resident's money in the same checking account. As of 6/28/13, the facility did not provide documentation for the water bill, mortgage payment, or bank statements. Therefore, the facility was not able to provide sufficient evidence that it had sufficient financial resource to ensure financial stability. 56. Observations on 06/25/13, 06/26/13, and 06/27/13 during the hours of 9 AM and 2 PM, confirmed that the facility's air conditioning unit was not working resulting in extremely uncomfortable temperatures for the residents. Confidential interviews with employees and residents confirmed the air conditioning unit has been broken for several weeks. During numerous interviews with the Owner/Administrator and Employee #1, it was also confirmed that the facility's air conditioning unit was broken and that the facility had no evidence of any attempts made to make repairs or service the unit. 57. During observation of the kitchen including the refrigerator, pantry, and cabinets was conducted on 6/25/13 at 10:45 AM by the two surveyors, it was noted the facility had an insufficient amount of food to accommodate the current census and the transfer residents. Inside the refrigerator the surveyor observed 4 gallons of water. The cook was present and confirmed that the only liquid in the refrigerator was water at that time. 15 58. At approximately 3:30 PM on 06/25/13, Employee #5 (the night staff) drove up to the facility and unloaded groceries including multiple gallons of milk and orange juice. When asked how frequently he replenishes the groceries, he stated once a week. 59. The facility's inability to ensure financial stability directly threatens the safety and well-being of all 18 residents (6 current residents and 11 additional residents). 60. Based on the foregoing facts, Kanlake Corporation Inc. violated Rule 58A- 5.021(1), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $2,500.00 and also gives rise to the revocation of the assisted living facility license. COUNT V KANLAKE CORPORATION INC. FAILED TO ENSURE THEY PROVIDED A SAFE, CLEAN, AND COMFORTABLE ENVIRONMENT FOR RESIDENTS. RULE 58A-5.023(3), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS II VIOLATION 61. | AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 62. A complaint investigation survey was conducted from June 24, 2013 through June 28, 2013. Based on observation and interviews, it was determined that the facility failed to ensure that they provided a safe, clean, and comfortable environment for 18 residents (6 current residents plus 11 additional residents). The findings include the following. 63. A tour of the facility was conducted on 6/24/13 at 9:15 AM with the Assistant Administrator, the following was observed. 16 64. A review of the thermostat revealed a reading of 90 degrees. The facility felt extremely hot (beyond the readings), even though the temperature reading was 90 degrees. During an interview with the Assistant Administrator on 6/24/13 at 10:00 AM, it was revealed she did not know the last time the air conditioner had been worked on or serviced. As of 6/28/13, the facility was not able to provide evidence they attempted to have the air conditioner serviced. 65. Confidential interviews conducted with residents revealed the air conditioner has not been working for a while and that they were extremely hot inside the facility. Many residents observed outside. When the residents were asked why they were outside, they consistently stated that it was cooler outside than inside. 66. Employee # 3 confirmed that the 2 large air conditioners had not been working for several weeks. He confirmed that the facility should have obtained assistance to fix the nonfunctioning system, but did not contact anyone until surveyor intervention on 6/24/13. Employee # 4 stated that she had contacted an Air Conditioner Repair Service but they were unaware of when they could come to the facility. When asked if she then attempted to get assistance from a different company, she stated that she did not. 67. The fence on the side of the house was missing multiple planks, broken and falling down. The doors to the metal shed were rusted and the shed falling apart exposing sharp edges. The wooden picnic table had a broken slat on top exposing sharp edges. 68. A window air conditioner unit in Resident Room #4 did not have a cover exposing the metal coils and electric. The door in the dining area leading outside did not properly fit the frame and was hard to open. The bottom of the door was rotted and the door in disrepair. 17 69. Bathroom #1 & #2 inside the building on the resident's side had visibly soiled tile floors, sinks, and baseboards. A brown dirt like substance was observed on the baseboards approximately 1/2 inch in height. 70. The walls of the resident side of the facility and the kitchen were greasy to the touch and heavily visibly soiled. The 4 doors to the resident rooms and bathrooms were splintered, heavily soiled, and in disrepair. The doors to the exterior of the house on the resident side were in the same condition. 71. All of the windows to the facility were closed despite the sweltering temperatures inside of the facility. 72. In the common area there were 3 tables. Two of the tables had tablecloths which were visibly soiled. 73. Asingle pitcher of water was positioned on a pass through ledge from the kitchen to the resident common area. There were 4 cups positioned by the pitcher for resident use. The facility census at the time of survey was 18 (6 current residents plus 11 additional residents). 74. The surveyor observed the two garbage cans positioned in the kitchen. One unlined can had discarded food in it and multiple small maggots like creatures moving around in the food. When asked how often the trash is emptied Employee #1 looked into the trash can and confirmed the presence of the moving maggot like creatures and stated it is emptied daily. 75. The surveyor asked Employee #1 if she would like to live in the facility and she stated, "Oh no!". She confirmed that the facility did not meet the standard of a clean, safe, and sanitary environment. 76. The aforementioned observed conditions directly threaten the safety and well- being of all 18 residents (6 current residents and 11 additional residents). 18 77. Based on the foregoing facts, Kanlake Corporation Inc. violated Rule 58A- 5.023(3), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $3,000.00 and also gives rise to the revocation of the assisted living facility license. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Kanlake Corporation Inc. on Counts I through V. 2. Revoke the assisted living facility license of Kanlake Corporation Inc. [License No.: 10609] based on the violations cited in Counts I through V. 2. Assess an administrative fine of $21,500.00 against Kanlake Corporation Inc. based on Counts I through V for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2012). 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 Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS 19 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 Alba M. Ciba) py fe. (\ a Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53” Street Suite 300 Miami, Florida 33166 305-718-5911 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. — Suite 500 Delray Beach, Florida 33484 (U.S. Mail) 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 Kamlawaty Lakrum, Administrator, . pied Kanlake Corporation Inc., 308 S. 30" Street, Fort Pierce, Florida 34947 on this // day of Sy , 2013. Alba M. vega“ C }- STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Kanlake Corporation Inc. AHCA No.: 2013006861 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed 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 must_be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 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. Phone: 850-412-3630 Fax: 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 Fine or Fee, or Administrative Complaint and I waive my right to object and to have a 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. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the 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, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 administrative 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. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC USPS.com® - Track & Confirm English Customer Service USPS Mobile B4USPS.COWVi Quick Tools Track & Contin Enter up to 10 Tracking aFind Find 38PS Locations: Buy Stamos “tack & Confirm ind a ZIP Code™ Ship a Package Hold Mail Change of Actress GET EMA UPOATES PRINT DETANS YOUR LABEL NUMBER SERVICE STATUS OF YOUR ITEM TovsnosoDnGGOs|s8209 Delivered Notice Left Depart USPS Sort Facility Processed through USPS Sort Facility Depart USPS Sort Facility Processed through USPS Sort Facility Check on Another Item What's your label (or receipt) number? Find ON USPS.cOM Government Services » Terms of Use > 8 FOIA> P: No FEAR Act EEG Data > Cu Service» Delivering Solutions to the Last Mile » Sie Index » SIUSPSSOM Copyright? 2073 USPS All Rights Reserved Manage Your Mail DATE & TIME July 29, 2013, 11:43 am July 19, 2013, 333 pm July 19, 2043. July 18, 2013, 10:02 pm July 18, 2013, July 17, 2013, 10:34 pm ON ABOUT.USPS.COM About USFS Home + Newsroom > USPS Service Alarts » Forms & Publications > Careers > https://tools.usps.com/go/TrackConfirmAction.action Page | of 1 Register / Siga In Search USPS com or rack Pi Shop LOCATION FEATURES FORT PIERCE, FL 34947 FORT PIERCE, Fl. 34947 WEST PALM BEACH, FL 33416 WEST PALM BEACH, FL 33416 OPALOCKA, FL 33054 OPA LOCKA, FL 33054 OTHER USPS SITES. Business Customer Gateway » Postal inspectors > inspector General : Postal Explorer > kages Business Solutions Certified Mail™ 08/08/2013

Docket for Case No: 13-003706

Orders for Case No: 13-003706