STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2015009231 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 ten thousand dollars ($10,000.00) based upon two (2) Class II deficiencies and a survey fee of five hundred dollars ($500.00) for a total assessment of ten thousand five hundred dollars ($10,500.00). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part IT, 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 F lorida, 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 in a 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. (k) At least 45 days’ notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days’ notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good - cause in a court of competent jurisdiction. Section 429.28(1)(a), Florida Statutes (2015). Ne” se 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 August 14, 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 medical neglect and failed to ensure rights related to relocation were protected including, but not limited to the failure to respond to an allegation of sexual assault, protect the victim and others from the alleged perpetrator, the failure to seek medical attention, and the discharge of a resident without allowing required notice, the same being contrary to the requirements of law. 11. That Petitioner’s representative reviewed the report of a local law enforcement agency ad noted as follows; a. On July 16, 2015, resident number ten (10) was interviewed by the police and reported that on July 14, 2015, at approximately 3:00 AM, the resident was sexually assaulted by another resident. b. The resident stated the resident reported this assault to the facility administrator on July 14, 2015. c. Respondent’s administrator confirmed she was made aware of the alleged assault on July 14, 2015, and decided not to call the police. woe! a 12. That Petitioner’s representative noted on July 22, 2015, that the reports of F lorida’s Department of Children and Families and law enforcement were generated from sources other than Respondent or its agents. 13. That Petitioner’s representative was informed by an investigator with the Florida Department of Children and Families that Respondent’s administrator indicated that she did not take resident number ten (10) to a local medical treatment facility after the resident told the administrator of a sexual assault as the administrator did not think she needed to; the administrator finally stating she took the resident to a local medical treatment center at the request of the resident’s adult child. 14. That Petitioner’s representative interviewed Respondent’s administrator on July 22, 2015, regarding resident number ten (10), and the administrator indicated as follows: a. The alleged incident of sexual assault on the resident occurred sometime between the hours of 2:00 AM and 4:00 AM on July 14, 2015. b. She became aware of the incident in the afternoon of July 14, 2015, when the resident came and told her about the incident. c. The resident came to talk with her and asked if they could talk in private. d. The administrator stated she told the resident “No,” and the resident needed to talk with the administrator with staff member “A” present. e. She did not report the incident to law enforcement or the Department of Children and Families because she did not believe the sexual assault of the resident had occurred. f. On July 15, 2015, the resident came to her complaining of a vaginal discharge and when the administrator was asked what action she took in response to the resident’s health complaint, the administrator responded that she took no action. 15. That Petitioner’s representative interviewed the adult child of resident number ten (10) on August 12, 2015, who indicated as follows: a. The adult child was notified about the alleged sexual assault of the resident on the evening on July 15, 2015. b. The adult child contacted the facility on July 16, 2015, and asked the administrator why the adult child’s parent had not been seen by a medical physician after the resident stated that the resident had been sexually assaulted. c. The administrator told the adult child that the administrator had planned to take the resident on July 15, 2015, but was too busy and would take the resident that day, July 16, 2015. d. The Respondent facility was aware that alleged predator had previously made threats of harm to the resident. 16. That Petitioner’s representative interviewed a detective with the local law enforcement agency on July 22, 2015, regarding resident number ten (10), and the detective indicated as follows: a. Law enforcement was contacted about allegations of an alleged resident on resident sexual assault on July 16, 2015, by a local medical facility. b. Resident number ten (10) was being treated at a local medical facility at the time local law enforcement was contacted. c. At the end of the examination, law enforcement contacted the facility to have the resident returned to the facility. wet’ a d. The facility refused to accept the resident back into the facility. e. The facility refused to provide the resident's medication and that two uniformed officers had to be sent to the facility to retrieve the resident's medications. 17. That Petitioner’s representative interviewed Respondent’s administrator on July 22, 2015, regarding resident number ten (10), and the administrator indicated as follows: a. She "refused” to accept the resident back into the facility. b. She refused to accept the resident back until law enforcement could provide a psychological evaluation. c. She had not provided the resident or the resident’s responsible party with a written discharge notice. d. The resident was taken to the hospital on July 16, 2015, due to the vaginal discharge. 18. That Petitioner’s representative interviewed resident number ten (10), an alert and aware individual, on July 24, 2015, and the resident indicated as follows: a. The resident had not made any comments about wanting to harm self or anyone else. b. The resident did not have any prior behavioral issues at the facility. c. The facility did not give the resident a forty-five (45) day notice of relocation or termination of residence at the facility. 19. That Petitioner’s representative reviewed Respondent’s discharge log and Respondent’s records related to resident number ten (10) during the survey and noted as follows: a. Resident number ten (10) was listed as discharged in the discharge log, on July 16, 2015, to a local medical treatment facility. se or The resident’s file did not contain any notices of discharge. The resident’s file did not document any incidents of the resident being a threat to self or others. 20. That Petitioner’s representative interviewed the adult child of resident number ten (10) on August 12, 2015, who indicated as follows: a. The adult child confirmed that the adult child was not provided with forty-five (45) day notice of relocation or termination prior to the Respondent refusing to accept the resident back into the facility. The adult child had to pick the resident up from the police station as the resident did not have a place to go after being discharged from the facility. 21. That the above reflects Respondents failure to ensure that it provided a safe and decent living environment, free from abuse and neglect, and honoring other resident rights, including but not limited to: a. b. Respondent’s failure to respond to an allegation of sexual assault. Respondent’s failure to protect the victim and others from an alleged perpetrator. Respondent’s failure to seek medical attention for a resident. Respondent’s failure to honor resident rights to notice of discharge. Respondent’s failure to provide services designed and implemented to address known sexually inappropriate behaviors exhibited by a resident. 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 (2015). 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 (2015). COUNT II 24, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth _ herein. 25. That Florida law provides “(1) ADMINISTRATORS. Every facility must be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of appropriate care to all residents as required by Chapters 408, Part II, 429, Part I, F.S. and Rule Chapter 59A-35, F.A.C., and this rule chapter.” Rule 58A-5.019(1), Florida Administrative Code. 26. That on August 14, 2015, the Agency completed a complaint survey of Respondent’s facility. 27. That based upon the review of records, observation, and interview, Respondent’s administrator failed to supervise an administrator the operation and maintenance of the facility including the management of all staff and the provision of appropriate care to all residents as required by law. 28. That Petitioner’s representative reviewed Respondent’s personnel records for its administrator on July 22, 2015, and noted as follows: a. The administrator was hired on November 1, 2013. b. Absent from the file was the following required documentation:! i. The administrator’s high school diploma or equivalent; ii. A job description; iii. Documentation the administrator had taken four (4) hours of training to assist residents with the self-administration of medication; or iv. Documentation from a health care provider stating the administrator was free from signs and symptoms of Tuberculosis (TB). 29. That Petitioner’s representative interviewed Respondent’s administrator on July 22, 2015 regarding her personnel records who indicated as follows: a. She was unable to locate her high school diploma. b. It would take several months to obtain the diploma from her home country of the Philippines. c. She had not made any attempts to try and get a copy of the diploma. d. She was not aware that she needed to have a job application or references in her file. e. She was unable to locate the statement that she was free of communicable disease and had her annual Tuberculosis (TB) test. f. She provides residents assistance with the self-administration of medication. g. She is not a licensed nurse in the State of Florida. h. She was unable to provide a copy of having completed training to provide ' These documents, and the requirement that they be maintained in facility personnel records, are mandated in Rules 58A-5.0191 and 58A-024, Florida Administrative Code. eed assistance with the self-administration of medication. 30. That Petitioner’s representative reviewed Respondent’s personnel records for its staff member “E” on July 22, 2015, and noted the following documents were not present: a. A job description; b. Verification of completion of HIV/AIDS training Cc. Verification of completion of training related to Do Not Resuscitate Orders; d. Verification of completion of training related to reporting major incidents; e. Verification of completion of training related to the facility's emergency procedures; f. Verification of completion of training related to resident rights; g. Verification of completion of training related to infection control; or h. Verification of completion of training related to resident behavior and needs and assistance with activities of daily living. 31. That Petitioner’s representative interviewed Respondent’s administrator on July 22, 2015 who, when asked to provide the job description and required documentation reflecting the training of staff member “E” regarding: HIV/AIDS; Do Not Resuscitate Orders; reporting major incidents; facility emergency procedures; resident rights; infection control; resident behavior and needs; and assistance with activities of daily living, indicated that she could not provide this information. 32. That Petitioner’s representative reviewed Respondent’s personnel records for its staff member “C” on July 22, 2015, and noted the following documents were not present:? a. Verification of completion of HIV/AIDS training ? See Footnote one (1) above. 3 See Footnote one (1) above. 10 b. Verification of completion of training related to Do Not Resuscitate Orders; c. Verification of completion of training related to reporting major incidents; d. Verification of completion of training related to the facility's emergency procedures; e. Verification of completion of training related to resident rights; f. Verification of completion of training related to recognizing and reporting resident abuse, neglect and exploitation. 33. That Petitioner’s representative interviewed Respondent’s administrator on July 22, 2015 who, when asked to provide the required documentation reflecting the training of staff member “C” regarding: HIV/AIDS; Do not Resuscitate Orders; reporting major incidents; facility emergency procedures; resident rights; and recognizing and reporting resident abuse, neglect and exploitation; indicated that she could not provide this information. 34. That Respondent is required to ensure that there are qualified staff on the premises to meet resident needs. (‘Notwithstanding the minimum staffing requirements specified in paragraph (a), all facilities, including those composed of apartments, must have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents’ scheduled and unscheduled service needs, resident contracts, and resident care standards as described in Rule 58A-5.0182, F.A.C.” Rule 58A-5.019(3)(b), Florida Administrative Code.) 35. That on July 22, 2015, Petitioner’s representative interviewed Respondent’s administrator regarding an alleged sexual assault of resident number ten (10) and the administrator indicated as follows: a. The resident came to speak with her at 4:00 PM on July 14, 2015. 11 The resident told her that resident number eleven (11) came into the room of resident number ten (10) between 2:00 AM and 4:00 AM and sexually assaulted resident number ten (10). On July 15, 2015, resident number ten (10) came to her complaining of a vaginal discharge. When asked what action she took after resident number ten (10) reported a vaginal discharge, the administrator said she took no action. e. On July 16, 2015, she transported resident number ten (10) to the hospital at the request of the resident’s adult child. She filed an adverse incident with the agency on July 20, 2015, six (6) days after becoming aware of the incident and four (4) days after an investigation was initiated by law enforcement. She understood the requirement that requires reporting an adverse incident within twenty-four (24) hours. She could not provide a reason for not reporting the incident and leaving the residents at risk. She could not state why she failed to contact law enforcement about the sexual assault. j. She had not provided a written forty-five (45) day discharge to resident number ten (10) or the family of the resident. When she was contacted by local law enforcement, she refused to accept resident number ten (10) back to the facility until local law enforcement provided a copy of a psychological evaluation. 12 se ae’ 36. That Petitioner’s representative reviewed Respondent’s policy and procedure for reporting Incidents and Filing of an Adverse Incident Report on July 22, 2015, and noted the following; a. The facility defined an incident as "any accident injury, skin treat resident altercation, fall medication error, abuse (suspected actual) or unusual circumstance of change.” b. The facility included events reported to law enforcement as Adverse Incidents. c. The policy and procedure further states, "Training and review of Policy and Procedures will be done to prevent further incidents and improve safety and care at the ALF." d. "Training on Reporting and Identifying Abuse, Neglect and Exploitation will be done on staff during initial training and annually thereafter. Completed training documents will be maintained on file in the facility." 37. That Petitioner’s representative reviewed Respondent’s adverse incident report regarding resident number ten (10) on July 22, 2015, and noted the following: a. The report was signed by the facility administrator on July 19, 2015 and date stamped on July 20, 2015. b. The cover sheet of the adverse incident report indicated that the adverse incident was resident number ten (10) having vaginal discharge. 38. That an adverse incident report must be filed within twenty-four (24) hours of the subject adverse incident. (“Licensed facilities shall provide within 1 business day after the occurrence of an adverse incident, by electronic mail, facsimile, or United States mail, a preliminary report to the agency on all adverse incidents specified under this section. The report must include 13 wet Sw information regarding the identity of the affected resident, the type of adverse incident, and the status of the facility’s investigation of the incident.” Section 429.23(3), Florida Statutes). 39. _ That Petitioner’s representative reviewed a local police report which reflected that law enforcement responded to the facility on July 16, 2015, to investigate an alleged sexual assault after having been notified of the allegation by a third party. 40. That Petitioner’s representative interviewed a detective with the local law enforcement agency on July 22, 2015, regarding resident number ten (10), and the detective indicated as follows: a. The facility refused to accept the resident back into the facility after the facility had dropped the resident off at the hospital. b. The facility refused to provide the resident's medication and that two uniformed officers had to be sent to the facility to retrieve the resident's medications. 41. That Respondent’s discharge log indicated that resident number ten (10) was discharged to the hospital on July 16, 2015. 42. That on July 22, 2015, Petitioner’s representative interviewed Respondent’s administrator who indicated as follows: a. The Respondent facility was the direct payee for the Social Security benefits of five (5) residents, residents numbered four (4), five (5), eight (8), fourteen (14), and eighteen (18). db. Respondent does not have a surety bond related to the resident benefits as “We have not gotten around to it.” 14 43. That an assisted living facility is required to maintain a surety bond where it or its agents ‘act as the representative payee for a resident’s benefits or entitlements. See, Section 429.27(2), Florida Statutes. 44. That the above reflects Respondent’s administrator failed to supervise an administrator the operation and maintenance of the facility including the management of all staff and the provision of appropriate care to all residents as required by law, including but not limited to: a. Respondent’s failure to protect residents from alleged sexually inappropriate behaviors of a resident. b. Respondent’s failure to ensure that an allegation of sexual assault was investigated as provided in Respondent’s policy and procedure. c. Respondent’s failure to report an alleged crime to law enforcement and the Department of Children and Families. d. Respondent’s failure to ensure that its staff are qualified and trained to provide care and services in the facility, e. Respondent’s failure to timely file an adverse incident report. f. Respondents failure to ensure the provision of a resident’s rights to required notice of discharge or relocation. g. Respondent’s failure to maintain a surety bond where Respondent is a direct payee for resident social security benefits. 45. 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. 46. That the same constitutes a Class II offense as defined by law, Section 408.813(2)(b), 15 Florida Statutes (2015). 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 (2015). COUNT HI 47. The Agency re-alleges and incorporates the above Counts I and II as if fully recited herein. 48. 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. 49. 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. 50. The above Agency survey of August 14, 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 further relief as this tribunal deems just. Respectfully submitted this day of September, 2015. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION 16 wee seca! The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1945 walsht@: yer By: Uj NOTICE 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. 7010 0780 0001 9836 2428 on September y , 2015 to Barbara Nemec, Administrator, Malaya Care, LLC d/b/a Henderson House ALF, 907 East Orange Avenue, Eustis, Florida 32726, and to Malaya Maulion, Registered Agent for Malaya Care, LLC, 907 East Orange Avenue, Eustis, Florida 32726. mas J. Walsh I Copy furnished to: Kriste Mennella, FOM Stephen Iglesias, Esq. Greenspoon Marder Law 401 East Jackson Street Suite 1825 Tampa. Florida 33602 = STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Malaya Care, LLC d/b/a Henderson House ALF AHCA No: 2015009231 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) 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 Compiaint, 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 18 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. A statement 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: (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: 19 gaaliS SECTION 07 East Orange Avenue = ustis, Florida 32726

Docket for Case No: 15-006973