STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. ; : AHCA No. 2015006021 MALAYA CARE, LLC d/b/a HENDERSON HOUSE ALF, 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, Malaya Care, LLC d/b/a Henderson House ALF (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2015), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of five thousand dollars ($5,000.00) based upon one (1) Class II deficiency and a survey fee of five hundred dollars ($500.00) for a total assessment of five thousand five hundred dollars ($5,500.00). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2015). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent is licensed as a one hundred forty-four (44) bed assisted living facility (“the Facility”), license number 6622, located at 907 East Orange Avenue, Eustis, Florida 32726. 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 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That Florida law provides: (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. Section 429.28(1)(a), Florida Statutes (2015). 8. That Florida law provides that all facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; and 2. Must be maintained free of hazards; and 3. Must ensure that all existing architectural, mechanical, electrical and structural systems and appurtenances are maintained in good working order. Rule 58A-5.0182(c), Florida Administrative Code. 9. That on May 6, 2015, the Agency completed a complaint survey of Respondent’s facility. 10. That based upon the review of records and interview, Respondent failed to ensure that it provided a safe and decent living environment, free from abuse and neglect including known behaviors of other residents and the provision of services to a resident exhibiting sexually inappropriate behaviors, the same being contrary to the mandates of law. 11. That Petitioner’s representative interviewed Respondent’s administrator on May 6, 2015, regarding resident number ten (10) and the administrator indicated as follows: a. The resident was arrested and removed from the facility by the police on April 10, 2015, for lewd battery on an elderly person. She did not find out about the resident touching resident number one (1) until April 6, 2015, when it was reported to her. _ When she found out she called Department of Children and Families, and she called family and told them that the resident had to be removed, but they refused to come and get the resident. When the resident touched resident number one (1) again on April 10, 2015, the police were called and the resident was arrested. 12. That Petitioner’s representative interviewed resident number two (2), an aware and alert individual, on May 6, 2015, who indicated as follows: a. b. Resident number ten (10) used to stare at the resident. Resident number ten (10) had grabbed at the resident’s breast and touched the resident back, which the resident did not like. The resident told staff and staff told resident number ten (10) to stop, which the resident did: This happened approximately three (3).months ago. 13. That Petitioner’s representative interviewed resident number five (5), an aware and alert individual, on May 6, 2015, who indicated as follows: a. The resident saw resident number ten (1) with the resident’s hand in the pants of resident number one (1), and resident number five (5) yelled for resident number ten (10) to stop which the resident did. Resident number ten (10) was caught in the room of resident number one (1) at four in the morning. “Staff knew [resident number ten (10)] was messing with [resident number one (1)] and staff would get after [resident number ten (10)] all the time.” 14. That Petitioner’s representative interviewed Respondent’s former staff member “B” on May 6, 2015, who indicated as follows: a. She had never observed any resident on resident abuse. b. She never saw resident number ten (10) touch or abuse another resident. c. None of the residents have ever told her they were touched or abused by resident number ten (10). d. When another staff member told her what resident number ten (10) did to resident number one (1), she called the Department of Children and Families and made a report. 15. That Petitioner’s representative interviewed resident number eight (8), an aware and alert individual, on May 6, 2015, who indicated as follows: a. Resident number ten (10) wanted to have sexual relations with resident number eight (8), but resident number eight (8) refused. wo wet db. The resident saw resident number ten (10) touch resident number one (1) under the resident’s clothes. c. The resident heard resident number ten (10) having sex with resident number six (6) in the room of resident number six (6) next door. d. The resident told staff member “B,” but she would not believe what resident number eight (8) said. 16. That Petitioner’s representative interviewed resident number nine (9), an aware and alert individual, on May 7, 2015, who indicated as follows: a. The resident saw resident number ten (10) touch resident number one (1) and resident number six (6), fondling and touching the residents’ private parts. b. The resident told a staff member, but the resident could not recall which staff member the resident had reported the behavior to. 17. That Petitioner’s representative interviewed Respondent’s former employee staff member “J” on May 7, 2015, who indicated as follows: a. She remembered resident number ten (10) from when she worked at Henderson House. b. Staff had reported to her that resident number ten (10) was observed grabbing resident number six (6) between the legs. c. She reported the incident to the Administrator. d. She also told the Administrator several times that resident number ten (10) was not appropriate for the facility because of the resident’s behavior. 18. That Petitioner’s representative reviewed a written statement, dated April 4, 2015, by a staff member which documented as follows: a. Observed resident number ten (10) rubbing the breast area of resident number one (1) up and down with the right hand. b. The staff member told resident number ten (10) to stop because that was abuse and sent the resident to the resident’s room. c. The staff member reported the incident to the team leader. 19. That Petitioner’s representative reviewed the observation log for resident number ten (10) during the survey and noted as follows: a. Documented was inappropriate interactions between the resident and other residents dating back as early as August 6, 2014, these entries reflecting the actual knowledge of Respondent by and through staff of the behaviors documented. b. Entries included: i. August 26, 2014 - It was reported to staff that resident number seven (7) saw resident number ten (10) rubbing the shoulders of resident number six (6). ii. September 26, 2014 — Have to watch [resident number ten (10)] when [] is by little [resident number six (6)], [resident number ten (10)] touches [resident number six’s (6)] bottom. iti. November 2, 2014 — Resident number ten (10) was kept from resident number one (1) all day. iv. November 5, 2014 -— Resident number ten (10) was observed touching resident number one (1) again, is rubbing on resident’s thigh. v. January 28, 2015 — Resident number ten (10) caught kissing resident number one (1) on the mouth. vi. vii. viii. ix. February 13, 2015 - Resident number ten (10) was rubbing resident number six’s (6) thigh this morning. “[] was making sounds like doing it.” March 7, 2015 — Staff member “C” talked with resident number ten (10) about touching other residents; was rubbing on resident number eight’s (8) arm and resident number eight (8) told resident number ten (10) to stop. March 21, 2015 — Resident number ten (10) was caught trying to touch resident number one (1). March 22, 2015 - Resident number ten (10) was caught rubbing on resident number six (6) and was trying to touch the resident’s breasts. 20. That Respondent allowed the inappropriate sexual activities of resident number ten (10) to continue and escalate with no planned and implemented intervention until the resident was arrested on April 10, 2015. 21. That the above reflects Respondent’s failure to ensure that it provided a safe and decent living environment, free from abuse and neglect, including but not limited to: a. Respondent’s failure to protect residents from known sexually inappropriate behaviors of a resident. b. Respondent’s failure to provide services designed and implemented to address known sexually inappropriate behaviors exhibited by a resident. c. Respondent’s failure to investigate and respond to allegations of abusive behavior made by residents. 22. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 23. That the same constitutes a Class II offense as defined by law, Section 408.813(2)(b), Florida Statutes (2014). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2014). COUNT II 24. The Agency re-alleges and incorporates the above Count I. 25. Section 429.19(7), Florida Statutes, provides: (7) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 429.28(3)(c) to verify the correction of the violations. 26. Section 429.28(3)(c), Florida Statutes, provides: (c) During any calendar year in which no survey is conducted, the agency shall conduct at least one monitoring visit of each facility cited in the previous year for a class I or class II violation, or more than three uncorrected class III violations. 27. The above Agency survey of May 6, 2015, found one or more Class II violations that will be the subject of a monitoring visit, or found one or more violations that were the subject of a complaint investigation, or both. WHEREFORE, the Agency intends to additionally impose a survey fee of five hundred dollars ($500.00) or as determined by this tribunal against Respondent, an assisted living facility in the State of Florida, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such mee! further relief as this tribunal deems just. Respectfully submitted this y day of August, 2015. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1945 walsht@ahca fy florida.com 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 I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7011 0470 0000 4509 4149 on August Yi , 2015 to Malaya Prado Maulion, Registered Agent of and Administrator for Malaya Care, LLC d/b/a Henderson House ALF, Malaya Care, LLC d/b/a Henderson House 4LF y nay Walsh II Copy furnished to: Kriste Mennella, FOM 10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Malaya Care, LLC d/b/a Henderson House ALF AHCA No: 2015006021 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 within 21 days 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. 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) J 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 ll 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. A statement of when the respondent received notice of the administrative complaint. 5. Astatement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License Type:___—=———SSSSSSs (ALF? Nursing Home? Medical Equipment? Other Type?) . Licensee Name: License Number: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I 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: Print Name: Title: 12 senna : aa ieee STs | SENDER: Ci E THIS SECTION COMPLETE

Docket for Case No: 15-006972