STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. Case No. 2013009492 GEORGIA’S PLACE, INC. D/B/A _GEORGIA’S PLACE, 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, Georgia’s Place, Inc, d/b/a Georgia’s Place (“Respondent”), pursuant to Sections 120.569 and 120.57, Fla. Stat. (2013), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility (“ALF”) to impose two $5,000 fines for two State Class I deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part IL, and 429, Part I, Fla. Stat. (2013). 2. Venue lies pursuant to Florida Administrative Code (“F.A.C.”) Rule 28-106.207. | | | i i PARTIES 3. The Agency is the regulatory authority responsible for licensure of ALFs and enforcement of all applicable State statutes and rules governing ALFs pursuant to Chapters 408, Part IT, and 429, Part I, Fla. Stat., and Chapter 58A-5, F.A.C., respectively. - 4, Respondent operates a 19 bed ALF at 2101 7" St S., St. Petersburg, FL 33705, license # 8966, with an additional Limited Mental Health (“LMH”) specialty license. 5 Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I - $5,000 CLASS I FINE (State Tag A0010 — Admissions — Continued Residency) 6. The Agency re-alleges and incorporates paragraphs 1 - 5 and Count I as if fully set forth herein. 7. On 31 July, 2013, the Agency commenced a complaint inspection (aka survey) (CCR. #2013007848). 8. The Agency’s surveyor learned the following information about resident #4, a 52 year old male, with an extensive criminal history and substantial prison time: a. Based on interviews and reviews of records, the facility failed to discharge resident #4 who exhibited inappropriate sexual and threatening behaviors toward resident #3, a vulnerable 37 year old female, and other abnormial behavior, which made him no longer appropriate for continued residency and which continued residency thereby enabled him to have the opportunity to eventually sexually assault resident #3. b. Resident #4's record revealed that he was readmitted to the facility on 2/23/13. He had previously been a resident from 9/28 - 12/23/12. He was diagnosed with a history of bipolar disorder on his health assessment, AHCA Form 1823, dated 2/25/13. The history and physical of a hospital admission dated 9/23/12 reported that the resident had a history of legal charges of . breaking and entering and armed robbery, and other crimes, and had served 9 years in prison. c. Interview with Staff A on 7/31/13 at about 12:10 PM. She revealed that resident #3 had reported to facility staff that resident #4 had made sexually explicit comments to her by a text message sent to her phone a couple of months ago. Resident #3 also told staff that resident #4 asked her to touch him sexually at a public bus stop. Staff A stated that staff told resident #3 to stay away from resident #4 and to never be alone with him. The employee also revealed that after resident #3 reported that she had been sexually assaulted, Staff A did not confront resident #4 because she was scared as he had threatened his sister the day before. Staff A stated that resident #4 said, "his sister didn't know who she was messing with and was lucky she's not dead and he didn't have one of his friends put a bullet in her." Staff A also stated she told the administrator what the resident had said and the administrator told her to call his sister and let her know what he was saying. Staff A told resident #4's sister and she stated that resident #4 had threatened that before but had not acted on it. Staff A also reported that resident #4 had also been verbally abusive to other residents. d. Interview with resident #3 on 7/31/13 at about 2:00 PM. She reported having been threatened by a knife and sexually assaulted by resident #4 on 7/26/13 in the bathroom of the facility's enclosed back porch. She had also previously told a staff member that resident #4 had a knife and had threatened to cut her throat if she ever ratted on him. The staff member told her that he was not supposed to have a knife and later told her that the staff member had searched his room but did not find a knife. e. Interview with the administrator 7/31/13 at about 4:00 PM. She stated that resident #4 had made advances to resident #3 during resident #4's first time at the facility and staff told her to stay away from him but resident #4 continued to buy her sodas and food and cigarettes. The administrator reported that she was told by resident #3 that resident #4 had sent her text messages with sexual content when he was readmitted to the facility around 2/13. The administrator stated resident #3 also told her about 3 weeks ago that resident #4 asked her to fondle him when they were going to a restaurant. The administrator stated that she told resident #3 to stop spending time with resident #4 as it was giving him double messages, f. Interview with Staff B 7/31/13 at about 8:00 PM. She stated that she had also been told by resident #3 that she had been sent a text message by resident #4 that stated what he wanted to do to her sexually. Staff B stated that the staff told resident #3 to stop sitting around him and detach herself because she may be giving him the wrong impression. . g. Interview with law enforcement on 8/2/13 at about 11:30 AM. The officer stated that resident #4 had been arrested on 7/26/13 for sexual battery and was still in custody. h. Review of resident #3's progress notes dated 7/26/13 reported that the resident had told the administrator several months ago about the text messages with sexual comments that resident #4 had sent her . She was encouraged to stay away from resident #4 as they had been spending time together. There were no other notes from 8/17/12 to 7/26/ 13 that addressed any of the sexual advances by resident #4. “i. Review of resident #4's progress notes dated from 2/23 - 6/18/13 did not reveal any notes that mentioned problem behaviors or reports of sexual advances to another resident. j. Review of Resident #4's resident contract which was signed by the resident on 2/23/13 indicated reasons for potential discharge. On page 2 of the contract, under the heading " Criteria - that would require the resident to leave the facility, ” number 2 states, " Ifthe resident's behavior becomes disruptive or disturbing to the extent that it interferes with the well-being of the other residents, such as keeping other residents awake at night, not respecting the rights and property of other residents, being verbally or physically abusive to other residents." k. The staff reported that they were aware of resident #4's sexual advances, both verbal and by text messages to resident #3 prior to the sexual assault. Facility staff just told her to stay away . from him and to never be alone with him. 1. There were no reports in the staff interviews or the residents' records about direct actions taken to resolve the concerns regarding resident #4's reported sexual advances toward resident #3. Resident #4's behavior was still not deemed "disruptive or disturbing", even though Staff A stated she was scared to confront him because he had left life threatening messages for his sister the day before the sexual assault and was verbally abusive to other residents. m. Further review of resident #4's record revealed that he was not given a notice to leave the facility even though his reported behavior met the criteria for discharge by law and as set forth in the facility's written contract with him. 9. Florida laws state the following as regards continued residency and discharge of an ALF resident: . 58A-5.0181 Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. (1) ADMISSION CRITERIA. An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: (g) Not be a danger to self or others as determined by a physician or mental health practitioner licensed under Chapters 490 or 491, F.S. (h) Not require licensed professional mental health treatment on a 24-hour a day basis. (n) Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on: 1, An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, F.S., and subsection (2) of this rule; 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a licensed health care provider at least every 3 years after the initial assessment, or after a significant | change, whichever comes first. A significant change is defined in Rule 58A- I 5.0131, F.A.C. The results of the examination must be recorded on AHCA Form ' 1823, which is incorporated by reference in paragraph (2) (b) of this rule. The | form must be completed in accordance with that paragraph. After the effective date of this rule, providers shall have up to 12 months to comply with this i requirement. . ; , (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (5) DISCHARGE. If the resident no longer meets the criteria for continued | residency, or the facility is unable to meet the resident’s needs, as determined by ; the facility administrator or licensed health care provider, the resident shall be discharged in accordance with Section 429,28(1), F.S, Rule 58A-5.0181, F.A.C. 10. In sum, the facility failed to discharge a male resident with a known extensive history of criminal misconduct and bipolar disorder which had evidenced itself to staff during a recent manic phase, who became verbally abusive to other residents and exhibited aggressive sexual and other threatening violent behavior towards a vulnerable female resident, to include specific ‘ i i | if i threats of violence against her with a knife and his sister prior to his sexually assaulting the resident. 11. 12. Respondent was cited for a State Class I offense, defined as follows: 408.813 Administrative fines; violations.—As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. ... Violations shall be classified on the written notice as follows: (a). Class “I” 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 present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. Section 408.813, Fla. Stat. (2013) The fine for an ALF Class I violation is set forth as follows: 429.19 Violations; imposition of administrative fines; grounds.— (1) In addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility, for the actions of any person subject to level 2 background screening under s. 408.809, for the actions of any facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. (2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (a) Class “I” violations are defined in s. 408,813, The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. (3) For purposes of this section, in determining if a penalty is to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated. (b) Actions taken by the owner or administrator to correct violations. (c) Any previous violations. (d) The financial benefit to the facility of committing or continuing the violation. (e) The licensed capacity of the facility. Section 429. 19, Fla. Stat, (2013) WHEREFORE, the Agency intends to impose a $5,000 fine against Respondent, an ALF in the State of Florida, pursuant to Sections 408.813 and 429.19, Fla, Stat. (2013). COUNT II - $5,000 CLASS I FINE (State Tag A0030 ~ Resident Care - Rights & Facility Procedures) 13. The Agency re-alleges and incorporates paragraphs 1 - 5 and Count I as if fully set forth herein. 14. On 31 July, 2013, the Agency commenced a complaint inspection (aka survey) (CCR #2013007848).. 15. | The Agency’s surveyor learned the following information about resident #3 during the survey: a. Based on interviews and record reviews, the facility failed to ensure resident #3’s right to live in a safe living environment free from abuse. b. Resident #3 was a 37 year old female who was admitted to the facility on 7/27/12 as a limited mental health resident. Her health assessment, AHCA Form 1823, dated 9/20/12, included diagnoses of impulse control disorder and a history of schizoaffective disorder. It also showed that she need supervision with preparing meals, shopping, handling personal affairs and handling her financial affairs. She also needed the facility to administer her medications which _ included medications for mood stabilization, anxiety, clear thoughts and depression. She received SSI disability income and had a social worker/ case worker assigned to her. Her Mental Health Resource Center FACT Program Comprehensive Recover Plan indicated as follows: “10-17-11: In the past 6 months (name) has been hospitalized 4 times, once for overdose and twice for suicidal thoughts 04-27-12: During the past 6 months (name) has been hospitalized 1 time for suicidal thoughts and cutting herself. Current Status: 10-27-12: During ihe past 6 months (name) has been hospitalized 5 times. She was hospitalized once for overdosing on Tylenol and once for burning herself. Her other hospitalizations were due to suicidal thoughts and ideations. She has been non adherent with her medications. She was a weekly schedule to meet with a LCSW to discuss techniques for copying with depression, etc. and monthly to meet with her doctor or other appropriate staff for brief therapy, symptom assessment, medication adherence and medication efficacy. Additional assistance was scheduled to address topics that included substance abuse and abstinence from alcohol and illegal drugs. “ Another entry read as follows: “Current Status: 10-27-12: In July (name) reported that a male residence has assaulted ‘her, She was hospitalized due to suicidal thoughts and ideation. She did not feel comfortable returning to Pinellas hope was hot comfortable having her return. She was moved to Elzadia’s ALF to provide (name) more supervision. She attempted suicide while there and was hospitalized, When (name) was released from the hospital she was placed at Georgia’s Place and ALF that provided more support and structure. ...” Another read as follows: “4-27-12: The court hearing was held on February 28, 201°2 and the person who raped (name) was convicted, sentenced to time served and will be deported...” c. Resident #4s health assessment. A review of Resident #4's record revealed that he was a resident at the facility the first time between 9/28 - 12/23/12. He was readmitted to the facility on 2/23/13. His health assessment, AHCA Form 1823 dated 2/25/13 listed a history of bipolar disorder for a diagnosis. The history and physical of a hospital admission dated 9/23/12 showed he had a history of legal charges of breaking and entering, armed robbery and other crimes and had served a total of 9 year's in prison. d. Interviews with Staff A on 7/31/13 at about 12:10 pm and with resident #3 at about 2:00 pm. Resident #3 reported that she was sexually assaulted on 7/26/13 by resident #4, who held a knife, in the bathroom on the facility's enclosed, back porch, He was arrested by law enforcement and removed from the facility. She reported to Staff A that she had wanted to cut herself directly after the assault. Staff A also stated that law enforcement found two knives in a fishing tackle box in resident #4’s room after the sexual assault but she denied knowing about his having a knife before the assault. e. Interview with Staff A on 7/31/13 at about 12:10 pm. Resident #3 reported to facility staff that resident #4 made sexually explicit comments to her by a text message sent to her phone a couple of months ago. Resident #3 also told staff that he had previously asked her to touch him sexually at a public bus stop. Staff A stated that staff told her to stay away from him 10 and to never be alone with him. Staff A also reported that after resident #3 reported she had been sexually assaulted that she did not confront him because she was scared because he had threatened his sister the day before. Staff A stated that resident #4 said, "his sister didn't know who she was messing with and was lucky she's not dead and he didn't have one of his friends put a bullet in her." Staff A stated she told the administrator what the resident had said and the administrator told her to call his sister and let her know what he was saying. Staff A told Resident #4's sister and she stated that Resident #4 had threatened that before but had not acted on it. Staff A reported that he had also been verbally abusive to other residents. f. Interview with resident #3 on 7/31/13 at about 2:00 pm. She went to a restaurant with Resident #4 about a month ago. At the bus stop, Resident #4 asked Resident #3 to touch him in a sexual manner. She stated that Resident #4 apologized and told her he would not do it again. She stated she did not go out with him to a restaurant again. Resident 8 also stated that Resident #4 sent her a couple of text messages to her phone a couple of weeks ago which were "nasty messages" about what he wanted to do to her sexually. Resident #3 stated that she reported these incidents to the facility staff and they told her to stay away from him and don't be by herself with Resident #4. After explaining that she had been threatened with a knife and then sexually assaulted on 07/26/13 by Resident #4, she stated that she had "told staff the week before that and the week before that, all the nasty things Resident #4 stated to her." Facility staff still told her to stay away from him and never be alone with him. Resident #3 had also previously told a staff member that resident #4 had a knife and had threatened to cut her throat if she ever ratted on him, The staff member told her that he was not supposed to have a knife and later told her that the staff member had searched his room but did not find a knife. . 11 g. Interview with the administrator on 7/31/13 at about 4:00 pm. Resident #4 had made advances to resident #3 during his first time at the facility and staff told her to stay away from him but he continued to buy her sodas and food and cigarettes. The administrator reported that she was told by resident #3 that resident #4 had sent her text messages with sexual content when he first was readmitted to the facility around 2/13. The administrator stated resident #3 also told her about 3 weeks ago that resident #4 told her to fondle him when they were going to a restaurant. The administrator stated that she told resident #3 to stop spending time with him as it was giving him double messages. The administrator stated that she didn't know what roll resident #3 played in going into that bathroom with him. There were other residents on the back porch when this happened and staff was in there but resident #3 did not call anyone for help. h. Interview with Staff B on 7/31/13 at about 8:00 pm. She had been told by resident #3 that she had been sent a text message from resident #4 in which he stated what he wanted to do to her sexually. Staff B stated that the staff told resident #3 to stop sitting around him and detach herself because she may be giving him the wrong impression. Staff B stated that resident #8 placed herself in this predicament because they told her to detach herself from him. i. Interview with law enforcement on 8/2/13 at about 11:30 am. Resident #4 had been arrested on 7/26/13 for sexual battery and was still in custody. ' _ j. Review of resident #3’s progress notes dated from 8/17/12 to 7/26/13. There were no notes about her telling staff about resident #4's sexually explicit phone texts until after the assault on 7/26/13. Resident #3's progress notes dated 7/26 13 addressed the sexual assault and reported that the resident had told the administrator several months ago about the text messages with sexual comments that he had sent io her. She was encouraged to stay away from him for they had been spending time together. 12 k. Review of resident #4's progress notes dated from 02/23/13 to 06/18/13. They reflected staff's’ observations of the resident; however, there was no mention of any problem behaviors or reports of sexual advances (in person or by text) from him to resident #3. 1, The facility staff reported that they were aware of resident #4's sexual advances, both verbal and by text messages to resident #3. Facility staff's only response was to instruct her to stay away from him and never be alone with him. m. Interview with the administrator on 7/31/13 at about 5:00 pm. She acknowledged that resident #3 may not have been feeling safe in the situation. n. There were no reports in the staff interviews or the residents’ records about direct actions taken to resolve the concerns regarding resident #4's reported sexual advances toward resident #3. This lack of action by facility staff impinged upon resident #3's right to live ina safe living environment, free of abuse. Resident #4 was arrested for sexual battery on resident #3 on 7/26/13. 16. Florida laws state the following regarding the rights afforded to and the care required for ALF residents: 429.28 Resident bill of rights. — (1) No resident of a 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 ina safe and decent living environment, free from abuse and neglect. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. Section 429.28, Fla. Stat. (2012) §8A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 13 (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: —~ (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. Rule 58A-5.0182, F.A.C. 17.. In sum, Respondent failed provide a safe living environment free from abuse and neglect ~ toa vulnerable woman with an extensive past history that included, inter alia, suicide attempts and depression regarding which the staff was aware and where the staff was also aware before the sexual assault that resident #4: 1) had an extensive criminal history to include substantial prison time, 2) suffered from bipolar disorder and had recently evidenced to staff a manic phase, 3) had previously approached her in sexually provocative manners at least two times away from the facility and had also texted her in sexually provocative manners such that she had complained to staff about the advances and texts nasty and filthy, 4) had previously threatened her with a knife, 5) had been verbally abusive to other residents, and 6) the day before the sexual assault had verbalized to a staff member a threat to have sister killed, such threat having scared the staff member so much that she was too fearful to confront him about it. Resident #3 had previously advised staff that resident #4 had a knife and had threatened her with it, and in fact law enforcement found two knives in his fishing tackle box in his room after the sexual assault. 18. Respondent was cited for a State Class I offense, as defined in paragraph 11. 19. The fine for an ALF Class I violation is set forth in paragraph 12. 14 WHEREFORE, the Agency intends to impose a $5,000 fine against Respondent, an ALF in the State of Florida, pursuant to Sections 408.813 and 429.19, Fla. Stat. (2013). Submitted this2“% day of January, 2014. STATE OF FLORIDA, AGENCY FOR BEALTH CARE ADMINISTRATION 525 Mirror Lake Dr. N., Suite 330H St. Petersburg, FL 33701 Ph: (727) 552-1942 a Edwin D. Selby, Esq. Fla. Bar No. 262587 NOTICE OF RIGHTS The Respondent is notified that it/he/she has 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/he/she has the right to be represented by an attorney in this matter. 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 ICERTIFY that a true and correct copy of the foregoing has beey served by U.S. Certified Mail, Return Receipt No. 7012 1640 0000 01 15 51155 ong? Ff January, 2014, to Administrator Georgia Lemon, Georgia’s Place, 2101 7® St. S., St. Petersburg, FL, 33705, and to Registered Agent Georgia Lemon, 2700 FL 33705 9" St. S., St. Petersburg... YQ Edwin D. Selby Ce: Patricia Caufman, AHCA Area 5 Field Office Manager 15 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Georgia’s Place, Inc. d/b/a Georgia’s Place, CASE NO. 2013009492 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 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. J 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; and 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) Thereby 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: Inistrator Georgia Lemon i _ -Georgia’s Place 2101 7th St. S. . St. Petersburg, FL, 33705

Docket for Case No: 14-002604