STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No.: 2017009524 File No.: 11953432 EDEN GARDENS, LLC d/b/a EDEN License No.: 8209 GARDENS ALF Provider Type: Assisted Living Facility Respondent. / ADMINISTRATIVE COMPLAINT 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, Eden Gardens, LLC, d/b/a Eden Gardens ALF (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action against an assisted living facility seeking the revocation of its license and the imposition of a $20,000.00 administrative fine and $500.00 survey fee. PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida. Ch. 408, Part II, and Ch. 429, Part I, Fla. Stat. (2017); Ch. 58A-5, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.812, 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2017). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2017). 2. The Respondent was issued a license by the Agency to operate this assisted living facility (“the Facility”) located at 12221 West Dixie Highway, Miami, Florida 3361, and was at all times material required to comply with the applicable state statutes and rules governing such facilities. 3. On August 4, 2017, the Agency issued an Emergency Suspension Order effective immediately, on the Respondent. As a license holder, the Respondent is a “licensee” as defined by Florida law. § 408.803(9), Fla. Stat. (2017) COUNT I Resident Rights Legal Requirements 4. Under Florida law: (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 in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Gj) Access to adequate and appropriate health care consistent with established and recognized standards within the community. § 429.28(1)(a), (b), G), Fla. Stat. (2017). 5. Under Florida law, in pertinent part: 58A-5.0182 Resident Care Standards. An assisted living facility must provide care and services appropriate to the needs of residents accepted for admission to the facility. (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Program must be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility must have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The telephone number for lodging complaints against a facility or facility staff must be posted in full view in a common area accessible to all residents. The telephone numbers are: the Long- Term Care Ombudsman Program, 1(888) 831-0404; Disability Rights Florida, 1(800) 342-0823; the Agency Consumer Hotline 1(888) 419-3456, and the statewide toll-free telephone number of the Florida Abuse Hotline, 1(800) 96-ABUSE or 1(800) 962-2873. The telephone numbers must be posted in close proximity to a telephone accessible by residents and must be a minimum of 14- point font. (d) The facility must have a written statement of its house rules and procedures that must be included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. The rules and procedures must at a minimum address the facility’s policies regarding: 1. Resident responsibilities; 2. Alcohol and tobacco; 3. Medication storage; 4. Resident elopement; 5. Reporting resident abuse, neglect, and exploitation; 6. Administrative and housekeeping schedules and requirements; 7. Infection control, sanitation, and universal precautions; and 8. The requirements for coordinating the delivery of services to residents by third party providers. Fla. Admin. Code R. 58A-5.0182(6). Survey Findings 6. On or about August 4, 2017, the Agency conduced a complaint investigation of the Facility. 7. Based upon observation, record review and interview, the Agency determined that Respondent’s Facility failed to provide a safe and decent living environment for the total of 104 residents. The Facility needed to be closed for the remediation of these conditions, and the residents were relocated. 8. The Agency conducted a tour of the Facility on or about August 4, 2017 in conjunction with the representatives from another state agency. 9. Live and dead bedbugs were found in rooms # 7, 28, 34, 35, 37, 38, 40 through 55, 62, 64, 66 and 67. Soiled mattresses with bed bug droppings and stains in rooms # 39, 67, 25, 26, 7 and 2. 10. In Room #55 bed B, a bed bug was observed crawling on the bed. The insect was caught and placed inside a plastic bag with some dead bed bugs shells. 11. On or about August 4, 2017 the Agency surveyor conducted interviews with Facility residents. 12. _ Resident #13 stated at “I used to have bed bugs about a month ago.” 13. Resident #54 stated that the Facility “had bedbugs very bad. I had to go into the hospital for a Jarge lump in my groin area. It turned out to be due to bedbug bites. I was moved to another room that didn't have handicap gear. I fell twice because there was no bar to help me get up. I hurt my bottom and got a new fracture.” 14. —_ Resident #9 stated that she had seen bed bugs in the room yesterday and Facility staff had not changed the mattress. 15. Resident #1 stated that he/she did have bed bugs in her room, but that he/she had never been bitten. 16. Resident #82 stated “I am being bitten” then proceeded to show the Agency surveyor two red punctures on his or her left forearm. 17. The Agency conducted a record review for Resident #82’s health assessment form. he or she has diagnosis of morbid obesity, Chronic Obstructive Pulmonary Disease, Parkinson’s, anxiety, bipolar disorder, non-insulin dependent diabetes mellitus and psychosis; tremors, poor balance, poor judgement and concentration. 18. The Agency further reviewed 58 resident health assessments, which revealed 13 residents had a diagnosis of diabetes (Residents #4, #37, #38, #65, #70, #76, #78, #82, #88, #92, #97, #100 and #104.) 19. Onor about August 4, 2017, the Agency interviewed Respondent’s Administrator. 20. The Administrator stated that the Facility had used a pest contro! company but later changed the company. She further stated that the pest control was being administered by sections. 21. The Administrator also stated that Resident #1 was examined at an outside medical facility, where they removed the resident’s coat and found a lot of bedbugs. Resident 1 was sent to the hospital and upon his/her return, he/she came back with another jacket that was given to him/her at the hospital. 22. The Administrator stated that even with the new coat, Resident #1 had a bed bug on his/her shoulder. 23. The Administrator finally stated that Facility staff went to Resident #1’s room and found one bed bug in the closet. The Administrator said Resident #1 was the only resident that has the bed bugs problem, nobody else has bedbugs. The Administrator attributed this to Resident #1 being “a hoarder and [bringing] clothes and books from thrift stores.” 24. On or about August 4, 2017, additional observations found dead rodents and fresh rodent droppings in rooms numbered 19, 21, 22, 27, 36, 37, and 63. 25. Lives roaches were observed in rooms numbered 7, 17, 20, and 28. Dead roaches, roach eggs, and roach droppings were found in rooms numbered 9, 28, 31, 38, and 63. Live ants were observed in storage in room #2. Dead insects were found throughout the rooms under beds, on floors and window sills. 26. On or about August 4, 2017, the Agency interviewed Facility residents about the rodents and insects. 27. Resident # 4 stated “I have a mouse in my room. I saw it last night.” 28. Resident # 54 stated, “We have roaches, flies, mice. People changed rooms several months ago due to mice.” 29. On or about August 4, 2017, the Agency reviewed resident medical records. The record review revealed the following. a. 3 sampled residents had diagnoses of an immunodeficiency virus. b. 16 sampled residents had a diagnosis of Chronic Obstructive Pulmonary Disease (Residents numbered 1, 4, 5, 28, 39, 54, 74, 76, 77, 82, 89, 93, 94, 95, 96 and 99.) Residents numbered 27 and 28 had a diagnosis of Chronic Bronchitis. c. 42 sampled residents had a diagnosis of psychosis (Residents numbered 1, 5, 11, 26, 27, 28, 29, 37, 38, 39, 43, 58, 59, 60, 61, 65, 66, 67, 68, 69, 72, 73, 74, 71, 80, 82, 87, 88, 89, 91, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103 and 104). d. 35 sampled residents had a diagnosis of insomnia (Residents numbered 1, 4, 5, 11, 26, 27, 28, 29, 38, 52, 53, 54, 56, 60, 61, 66, 67, 68, 72, 73, 74, 77, 82, 87, 88, 89, 93, 94, 98, 99, 100, 101, 102, 103 and 104). e. 12 sampled residents had a diagnosis of major depression (Residents numbered. 1, 4, 28, 66, 67, 68, 70, 89, 93, 96, 97 and 99). f. 3 sampled residents had a diagnosis of schizophrenia paranoid type (Residents numbered 64, 77 and 91). g. 9 sampled residents required wheelchair use (Residents numbered 39, 43, 52, 54, 61, 72, 82, 95 and 96). bh. 18 sampled residents required assistance with bathing (Residents numbered 12, 39, 43, 51, 55, 58, 66, 70, 72, 72, 77, 78, 82, 90, 94, 95, 96 and 103) and 5 sampled residents required assistance with dressing (Residents 43, 55, 72, 95 and 96) . 30. | A review of the health assessment of 58 residents showed the overall physical and psychological vulnerability of the resident population to these infestations due to their diagnosed health conditions. 31. Accordingly, the Respondent was cited for a class J violation. Remedy 32. | Under Florida law, 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 section 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. § 429.191), Fla. Stat. (2017). 33. Under Florida law, class I violations are defined in section 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. § 429.19(2)(a), Fla. Stat. (2017). 34. Under Florida law, 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 J 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. § 408.813(2)(a), Fla. Stat. (2017). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $10,000.00. COUNT I Physical Plant — Safe Living Environment Legal Requirement 35. Under Florida law: (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident; 2. A closet or wardrobe space for hanging clothes; 3. A dresser, chest or other furniture designed for storage of clothing or personal effects; 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and 5. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. (d) Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be threadbare. Fla. Admin. Code R. 58A-5.023(3), (2017). Survey Findings 36. The Agency re-alleges and incorporates by reference the survey findings in Count 37. | Onor about August 4, 2017, the Agency conduced a complaint investigation of the Facility. 38. Based upon observation, record review and interview, the Agency determined that Respondent’s Facility failed to provide a safe living environment, free of hazards and failed to ensure that that all existing architectural, mechanical, electrical and structural systems, and appurtenances were maintained in good working order for 104 residents. 39. On or about August 4, 2017, the Agency toured Respondent’s Facility in conjunction with the representatives from another state agency. The Agency surveyors observed numerous physical plant violations. 40. Furniture and fixtures throughout the Facility were accumulating dust, food residue, and dead insects. Several windows were not screened and were not properly sealed. The doors leading to the outside on annex, northeast and northwest wing were not vermin proof. Several openings around the exterior of building needed to be sealed or screened to prevent vermin, rodent and insect harborage. 41. There was limited or no lighting in bedrooms and bathrooms for rooms numbered 22, 24, 25, 26, 27, 30 and 31. 42. In room number 53, there was a very old mattresses with stains, dead cockroaches, and dead bedbugs on it. 43. In room number 50, paint was missing from the wall. 44. Room number 45 was full of magazines, television, boxes, and other debris scattered on the floor, which belonged to a resident who had moved out months earlier. 45. — Respondent’s Facility maintenance man removed a mattress and box spring with a soiled cover, taking it into room number 7 to replace a mattress that may have been infested with bedbugs. 46. In room number 62, there were live and dead bugs and an old mattress. 47. In room number 64, the left side bar of bed A was broken and the box spring on bed A had stains from bed bugs. 48. In room number 49, bed B the mattress was sunken. 49. In room number 22, the mattress was worn. 50. In rooms numbered 2, 7, 25, 26, 39 and 67, the mattresses were soiled with bedbug droppings and stains. 51. In room number 2, an electric socket was missing. 52. In room number 38, on the front of the room, the roof was unfinished. 53. In room number 28, the bathroom paint was peeling from the wall. 54. In room numbers 22 and 25, the windowpanes were broken. Also, in room number 22, the window ledge was broken. 10 55. In room number 17, the ceiling was cracked close to light fixture. 56. Dead insects were throughout the rooms under beds, on floors, and windowsills. 57. | Onor about August 4, 2017, the Agency interviewed Respondent’s Administrator. 58. The Administrator stated that the Facility was doing regular pest control and was under treatment for bedbugs. If the Facility identified a problem, it would do heat, vacuum, steam and spray. The last pest control visit was on June 15th. 59. The Administrator continued to state that a resident that found a bedbug and the Facility replaced the mattress and the box spring as a preventive measure. Additionally, the Facility had a meeting with 6 or 7 residents on July 22, 017 that are “hoarders.” 60. The Administrator added that the residents were informed that any resident who brings things from the used items stores, the Facility would check what they brought and treat it with heat. 61. On or about August 4, 2017, the Agency interviewed Respondent’s Staff D. 62. Staff D stated he would use bedbug treatments outside the rooms and then when the residents had a problem, Staff A would tell him to treat the rooms. Staff D said this started as far back as May and June in 2017. 63. Onor about August 4, 2017, Department of Health (“DOH”) inspectors went into the kitchen and stopped staff from serving lunch to the residents because of “gray water.” 64. Pursuant to Rule 58A-5.0161(a), F.A.C., DOH is delegated the authority to inspect licensed facilities in matters relating to food hygiene. 65. The grey water was described as wastewater that was a part of the sewer system, which was entering the kitchen through a floor drain. The water had a very bad odor. 66. | The DOH found that once there is back flow from the sewer, the Facility kitchen 11 cannot be used. The Facility needed to discard all the food that was prepared and get food from the outside for the residents to have lunch. 67. | The DOH inspection also found: a. Inthe room where the emergency food was stored, there was no light. b. The fryer had very old, black, and dirty oil. c. A dead rat was found outside of the kitchen exit, amid multiple empty cans of cat food. 68. | The Agency conducted further interviews with Respondent’s Administrator. 69. The Administrator stated she was not able to provide any copies of receipts or records from pest control companies from January to July of 2017. She further stated that the pest control company had sent the reports to the corporate office, together with the ones from the other facilities that they manage, and that they would have to separate the records in order to provide it. 70. She finally stated that the Facility had changed the pest control company recently, perhaps as recent as July. 71. Accordingly, the Agency cited Respondent with a Class I deficiency. Remedy 72. Under Florida law, class I violations are defined in section 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. § 429.19(2)(a), Fla. Stat. (2017). 73. Under Florida law, 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 12 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. § 408.813(2)(a), Fla. Stat. (2017). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $10,000.00. COUNT Ill Assessment of Survey Fee 74. The Agency re-alleges and incorporates by reference Counts I and II. 75. 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 400.428(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(10), Fla. Stat. (2017). 76. The Agency received a complaint about Respondent’s Facility. 77. In response to the complaint, the Agency conducted a complaint survey of the Respondent’s Facility. 78. Based upon the survey, the Agency found a violation that was the subject of the complaint. 79. In this instance, the Agency is entitled to a survey fee of $500.00. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a survey fee of $500.00 against the Respondent. COUNT IV 13 License Revocation 80. The Agency re-alleges and incorporates by reference Counts I and II. 81. Under Florida law, in addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, any person subject to level 2 background screening under s. 408.809, or any facility staff: (a) an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility ... (e) A citation for any of the following violations as specified in s. 429.19: 1.One or more cited class I violations. § 429.14(1)(a), (e), Fla. Stat., (2017). 82. The Respondent’s actions and/or inactions constituted an intentional or negligent act that seriously and/or materially affected the health, safety or welfare of one or more of the residents of the Facility. 83. The Respondent’s actions or inactions constituted two separate class I violations. 84. The Respondent’s actions or inactions constituted a violation of this Chapter 408, Part II, the authorizing statutes, or the applicable rules. 85. Under Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: ... (b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c) A violation of this part, authorizing statutes, or applicable rules. § 408.815(1)(b), (c), Fla. Stat. (2017). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to revoke the Respondent’s license to operate an assisted living facility. 14 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Makes findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully submitted on this 23rd day of August, 2017. Aruban; mau Ss oa Florida Bar No. 0104832 The Sebring Building Agency for Health Care Administration 525 Mirror Lake Drive N., Suite #330 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28- 106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 15 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form have been served to the below named persons at the address stated by the method designated on this 23rd day of August, 2017. Aecd Andrew B. Thornquest, Senior Att mey Florida Bar No. 104832 Office of the General Counsel Agency for Health Care Administration The Sebring Building 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1942 Facsimile: (727) 552-1940 Andrew. Thornquest@ahca.myflorida.com Administrator Eden Gardens ALF 12221 West Dixie Highway North Miami, Florida 33161-5427 (Certified Mail- 7016 2140 0001 1591 9659) Peter A. Lewis, Esquire Law Offices of Peter A. Lewis, P.L. 3023 N. Shannon Lakes Drive, Suite 101 Tallahassee, Florida 32309 (Electronic Mail) 16 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Eden Gardens, LLC AHICA No. 2017009524 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. The Election of Rights form may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you received the Administrative Complaint. If your Election of Rights form with your selected option (or request for hearing) is not timely received by the Agency Clerk, the right to an administrative hearing to contest the proposed agency action will be waived and an adverse Final Order will be issued. In addition, please send a copy of this form to the attorney of record who issued the Administrative Complaint. (Please use this form unless you, your attorney or your qualified representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) The address for the Agency Clerk is: Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3, 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) 1 waive the right to a hearing to contest the allegations of fact and conclusions of law contained in the Administrative Complaint. 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 fine, sanction or other agency action. OPTION TWO (2) I admit the allegations of fact contained in the Administrative Complaint, but I wish to be heard at an informal hearing (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, sanction or other agency action should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Administrative Complaint and 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 17 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. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (Optional) Thereby 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: 18 Tracking Number: 70162140000115919659 Status Not Available The tracking number may be incorrect or the status update is not yet available. Please verify your tracking number and try again later.

Docket for Case No: 17-005291