STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. , AHCA No. 2016003817 LOVES SENIORS HOME INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State Of Florida, Agency For Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Love’s Seniors Home Inc. (hereinafter “the Respondent”), pursuant to sections 120.569 and 120.57, Florida Statutes (2015), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of ($500.00), based upon one uncorrected class III deficiency and a survey fee in the amount of $356.26. PARTIES 2. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapter 408, Part II, Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 3. The Respondent operates a six bed assisted living facility located at 450 Sail LN, Merritt Island, FL 32953, and is licensed as an assisted living facility, and was at all times material hereto required to comply with all applicable rules and statutes. 4, Pursuant to Section 429.24, Floirda Statutes a facility shall: (1) The presence of each resident in a facility shall be covered by a contract, executed at the time of admission or prior thereto, between the licensee and the resident or his or her designee or legal representative. Each party to the contract shall be provided with a duplicate original thereof, and the licensee shall keep on file in the facility all such contracts. The licensee may not destroy or otherwise dispose of any such contract until 5 years after its expiration. (2) Each contract must contain express provisions specifically setting forth the services and accommodations to be provided by the facility; the rates or charges; provision for at least 30 days’ written notice of a rate increase; the rights, duties, and obligations of the residents, other than those specified in s. 429.28; and other matters that the parties deem appropriate. Whenever money is deposited or advanced by a resident in a contract as security for performance of the contract agreement or as advance rent for other than the next immediate rental period: (a) Such funds shall be deposited in a banking institution in this state that is located, if possible, in the same community in which the facility is located; shall be kept separate from the funds and property of the facility; may not be represented as part of the assets of the facility on financial statements; and shall be used, or otherwise expended, only for the account of the resident. (b) The licensee shall, within 30 days of receipt of advance rent or a security deposit, notify the resident or residents in writing of the manner in which the licensee is holding the advance rent or security deposit and state the name and address of the depository where the moneys are being held. The licensee shall notify residents of the facility’s policy on advance deposits. (3)(a) The contract shall include a refund policy to be implemented at the time of a resident’s transfer, discharge, or death. The refund policy shall provide that the resident or responsible party is entitled to a prorated refund based on the daily rate for any unused portion of payment beyond the termination date after all charges, including the cost of damages to the residential unit resulting from circumstances other than normal use, have been paid to the licensee. For the purpose of this paragraph, the termination date shall be the date the unit is vacated by the resident and cleared of all personal belongings. If the amount of belongings does not preclude renting the unit, the facility may clear the unit and charge the resident or his or her estate for moving and storing the items at a rate equal to the actual cost to the facility, not to exceed 20 percent of the regular rate for the unit, provided that 14 days’ advance written notification is given. If the resident’s possessions are not claimed within 45 days after notification, the facility may dispose of them. The contract shall also specify any other conditions under which claims will be made against the refund due the resident. Except in the case of death or a discharge due to medical reasons, the refunds shall be computed in accordance with the notice of relocation requirements specified in the contract. However, a resident may not be required to provide the licensee with more than 30 days’ notice of termination. If after a contract is terminated, the facility intends to make a claim against a refund due the resident, the facility shall notify the resident or responsible party in writing of the claim and shall provide said party with a reasonable time period of no less than 14 calendar days to respond. The facility shall provide a refund to the resident or responsible party. within 45 days after the transfer, discharge, or death of the resident. The agency shall impose a fine upon a facility that fails to comply with the refund provisions of the paragraph, which fine shall be equal to three times the amount due to the resident. One-half of the fines shall be remitted to the resident or his or her estate, and the other half to the Health Care Trust Fund to be used for the purpose specified in s. 429.18. (b) Ifa licensee agrees to reserve a bed for a resident who is admitted to a medical facility, including, but not limited to, a nursing home, health care facility, or psychiatric facility, the resident or his or her responsible party shall notify the licensee of any change in status that would prevent the resident from returning to the facility. Until such notice is received, the agreed-upon daily rate may be charged by the licensee. (c) The purpose of any advance payment and a refund policy for such payment, including any advance payment for housing, meals, or personal services, shall be covered in the contract. (4) The contract shall state whether or not the facility is affiliated with any religious organization and, if so, which organization and its general responsibility to the facility. (5) Neither the contract nor any provision thereof relieves any licensee of any requirement or obligation imposed upon it by this part or rules adopted under this part. (6) In lieu of the provisions of this section, facilities certified under chapter 651 shall comply with the requirements of s. 651.055. (7) Notwithstanding the provisions of this section, facilities which consist of 60 or more apartments may require refund policies and termination notices in accordance with the provisions of part II of chapter 83, provided that the lease is terminated automatically without financial penalty in the event of a resident’s death or relocation due to psychiatric hospitalization or to medical reasons which necessitate services or care beyond which the facility is licensed to provide. The date of termination in such instances shall be the date the unit is fully vacated. A lease may be substituted for the contract if it meets the disclosure requirements of this section. For the purpose of this section, the term “apartment” means a room or set of rooms with a kitchen or kitchenette and lavatory located within one or more buildings containing other similar or like residential units. 4, Under Florida law, the facility may not levy an additional charge for any supplies, services, or accommodations that the facility has agreed by contract to provide as part of the standard daily, weekly, or monthly rate. The resident or resident’s representative must be furnished in advance with an itemized written statement setting forth additional charges for any services, supplies, or accommodations available to residents not covered under the contract. An addendum must be added to the resident contract to reflect the additional services, supplies, or accommodations not provided under the original agreement. Such addendum must be dated and signed by the facility and the resident or resident’s legal representative and a copy given to the resident or resident’s representative. 58A-5.025(3), Fla. Admin Code. 5. On or about November 9, 2015, the Agency conducted a complaint survey of the Respondent. 6. Based on record review and interview, the facility failed to honor refund policy for resident #4 in facility's resident's contract. 7. Record review revealed there was an addendum made to the resident's (#4) contract. However, this addendum was not part of the original contract the resident signed on 6/8/2015 date. This addendum required the resident to pay the next month's rent if a 30 day notice was not given. The original contract signed by resident #4’s Power of Attorney did not indicate the terms of vacating the facility without providing the facility a 30 day notice, you must pay the next month payment. 8. During an interview on 2/15/2016 at 5 PM with the administrator who confirmed she did not refund payment to resident #4, because the resident's friend who signed resident #4 out from the facility on 7/29/2015 signed a letter understanding that a "30 day notice" was not given, therefore resident #4 required to pay August 2015 payment. The Administrator also confirmed that she recently added addendum to the resident's contract agreement in reference to paying the next month if you do not give a 30 day notice. 9. The administrator was informed the addendum was added after the resident signed the original contract. The resident's friend was not her power of attorney. 10. The Respondent’s actions of inactions constitute a Class three deficiency. 11. Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. 408.813(2)(c), Fla. Stat. (2015). 12. A citation for a class [I violation must specify the time within which the violation is required to be corrected. If a class mM violation is corrected within the time specified, a fine may not be imposed. 408.813(2)(c), Fla. Stat. (2015) 13. The Respondent was given thirty days to correct the cited class three deficiency. 14. On or about February 10, 2016, the Agency conducted a complaint survey of the Respondent. 15. Based on record review and interview, the facility failed to honor refund policy for resident #4 in facility's resident's contract. 16. Record review revealed there was an addendum made to the resident's (#4) contract. However, this addendum was not part of the original contract the resident signed on 6/8/2015 date. This addendum required the resident to pay the next month's rent if a 30 day notice was not given. The original contract signed by resident #4's Power of Attorney did not indicate the terms of vacating the facility without providing the facility a 30 day notice, you must pay the next month payment. 17. During an interview on 2/15/2016 at 5 PM with the administrator who confirmed she did not refund payment to resident 44, because the resident's friend who signed resident #4 out from the facility on 7/29/2015 signed a letter understanding that a "30 day notice" was not given, therefore resident #4 required to pay August 2015 payment. The Administrator also confirmed that she recently added addendum to the resident's contract agreement in reference to paying the next month if you do not give a 30 day notice. 18. The administrator was informed the addendum was added after the resident signed the original contract. The resident's friend was not her power of attorney. 19. The Respondent’s actions of inactions constitute an uncorrected Class three deficiency. 20. Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. 408.813(2)(c), Fla. Stat. (2015). 21. A citation for a class II violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. 408.813(2)(c), Fla. Stat. (2015). 22. Under Florida law, the agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. § 429.19(2)(b), Fla. Stat. (2015). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500.00 against the Respondent. COUNT I Assessment of Survey Fee 23. The Agency re-alleges and incorporates by reference Count I. 24. The Agency received a complaint about the Respondent. 25. In response to the complaint, the Agency conducted a complaint survey of the Respondent and its Facility. 26. As a result of the complaint survey, the Respondent was cited for a violation of Florida law as it relates to assisted living facilities. 27. The basis for the violations alleged in this Administrative Complaint relates to the complaints made against the Respondent and its Facility. 28. Under Florida law, 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 Section 429.28(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(7), Fla. Stat. 29. In this particular instance, the Agency is entitled to assess a survey fee against the Respondent in the amount of $491.68. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose a survey fee of $491.68 against the Respondent. /s/John Bradley John Bradley, Esquire Fla. Bar. No. 92277 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1944 (office) John.Bradley@ahca.myflorida.com NOTICE THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. 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, BLDG 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form has been served to: Antina Reed, Administrator, Love Seniors Home Inc., 450 Sail LN, Merritt Island, FL 32953 by U.S. Certified Mail (7011 0470 00004509 4842), this 21 day of June, 2016.. s/John Bradley John Bradley, Esquire Fla. Bar. No. 92277 Agency for Health Care Admin. §25 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1944 (office) 727.552.1440 (facsimile) John.Bradley@ahca.myflorida.com Copy furnished to: Theresa DeCanio, Field Office Manager Catherine Avery, Assisted Living unit Manager STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Love Seniors Home Inc. AHCA No: 2016003817 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 Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. 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: 10 ieee COMPLETE THIS SECTION QQMDELIVERY ‘450 Sail EN ; erritt Island; FL 32953

Docket for Case No: 16-005575

Orders for Case No: 16-005575