STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2018003250 2017011855 VILLA SERENA II, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Villa Serena II (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2018), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine of $1,500 and assess a survey fee of $458.75 against the Respondent for three uncorrected class III violations. PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Ch. 408, Part II, Ch. 429, Part I, Fla. Stat. (2018); 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. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2018). 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. (2018). 2. The Respondent was issued a license by the Agency to operate an assisted living facility (“the Facility”) located at 60 NW 33™ Ave., Miami, Florida 33125, and was at all times material required to comply with the applicable statutes and rules governing assisted living facilities. COUNT I Staffing Standards—Administrator 3. Under Florida law, (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. (a) An administrator must: 1. Be at least 21 years of age; 2. If employed on or after October 30, 1995, have, at a minimum, a high school diploma or G.E.D.; 3. Be in compliance with Level 2 background screening requirements pursuant to sections 408.809 and 429.174, F.S.; 4. Complete the core training and core competency test requirements pursuant to tule 58A-5.0191, F.A.C., no later than 90 days after becoming employed as a facility administrator. Administrators who attended core training prior to July 1, 1997, are not required to take the competency test unless specified elsewhere in this rule; and, 5. Satisfy the continuing education requirements pursuant to rule 58A-5.0191, F.A.C. Administrators who are not in compliance with these requirements must retake the core training and core competency test requirements in effect on the date the non-compliance is discovered by the agency or the department. (b) In the event of extenuating circumstances, such as the death of a facility administrator, the agency may permit an individual who otherwise has not satisfied the training requirements of subparagraphs (1)(a)4. of this rule, to temporarily serve as the facility administrator for a period not to exceed 90 days. During the 90 day period, the individual temporarily serving as facility administrator must: 1. Complete the core training and core competency test requirements pursuant to rule 58A-5.0191, F.A.C.; and, 2. Complete all additional training requirements if the facility maintains licensure as an extended congregate care or limited mental health facility. (c) Administrators may supervise a maximum of either three assisted living facilities or a group of facilities on a single campus providing housing and health care Administrators who supervise more than one facility must appoint in writing a separate manager for each facility. However, an administrator supervising a maximum of three assisted living facilities, each licensed for 16 or fewer beds and all within a 15 mile radius of each other, is only required to appoint two managers to assist in the operation and maintenance of those facilities. (d) An individual serving as a manager must satisfy the same qualifications, background screening, core training and competency test requirements, and continuing education requirements as an administrator pursuant to paragraph (1)(a) of this rule. Managers who attended the core training program prior to April 20, 1998, are not required to take the competency test unless specified elsewhere in this rule. In addition, a manager may not serve as a manager of more than a single facility, except as provided in paragraph (1){c) of this rule, and may not simultaneously serve as an administrator of any other facility. (e) Pursuant to section 429.176, F.S., facility owners must notify the Agency Central Office within 10 days of a change in facility administrator on the Notification of Change of Administrator form, AHCA Form 3180-1006, June 2016, which is incorporated by reference and available online at: http://www. flrules.org/Gateway/reference.asp?No=Ref-09393. Fla. Admin. Code R. 58A-5.019(1) (2018). 4. Under Florida law, 429.176 Notice of change of administrator—lIf, during the period for which a license is issued, the owner changes administrators, the owner must notify the agency of the change within 10 days and provide documentation within 90 days that the new administrator has completed the applicable core educational requirements under s. 429.52. A facility may not be operated for more than 120 consecutive days without an administrator who has completed the core educational requirements. §429.176, Fla. Stat. (2018). Facts 5. A Complaint Survey of Respondent’s facility was conducted on 08/10/16 and concluded on 08/12/16. 6. Based on record review and interview, the facility failed to appoint a separate Manager for each facility the Administrator supervised. The Administrator supervised three assisted living facilities. 7. Record review found the facility's Administrator supervised three assisted living facilities. There was no documentation that the facility appointed a manager for the facilities. 8. In an interview conducted on 8/10/16 at 7:30 pm, the facility Administrator stated "Staff B is the facility's manager. She took the Core training recently. She will do the test soon." The Administrator confirmed that there was no documentation that Staff B was appointed as a facility manager. 9. The Respondent was cited for a class III violation. 10. A Complaint Revisit Survey of Respondent’s facility was conducted on 12/19/16 and concluded on 12/22/16. 11. Based on record review and interview, the facility failed to appoint a Manager. The Administrator supervised three assisted living facilities. 12. Record review found the facility's administrator supervised three assisted living facilities. There was no documentation that the facility appointed a manager for the facilities. 13. Clearinghouse review revealed no manager listed in the employee roster. 14. In an interview conducted on 12/20/16 at 5:30 pm, the facility administrator stated "Staff B is the facility manager. She took the Core test recently." 15. Record review found Staff B (hired 12/07/15) did not successfully pass the CORE competency exam. 16. | The Respondent was cited for an uncorrected class III deficiency. Sanction 17. Under Florida law, in addition to the requirements of part I] 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. § 429.14(1), Fla. Stat. (2018). 18. Under Florida law, violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. Violations shall be classified on the written notice as follows: 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. A citation for a class III 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. (2018). 19. 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)(c), Fla. Stat. (2018). 20. The Agency cited the Respondent for a Class [II violation in accordance with applicable statutes and authorizing rules and it remained uncorrected. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500.00 against the Respondent for an uncorrected class II violation. COUNT I Resident Rights 21. The Agency re-alleges and incorporates by reference paragraphs 1-2 and Count | through Count II as if fully set forth herein. 22, 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. * * * (3)(a) The agency shall conduct a survey to determine general compliance with facility standards and compliance with residents’ rights as a prerequisite to initial licensure or licensure renewal. The agency shall adopt rules for uniform standards and criteria that will be used to determine compliance with facility standards and compliance with residents’ rights. (b) In order to determine whether the facility is adequately protecting residents’ rights, the biennial survey shall include private informal conversations with a sample of residents and consultation with the ombudsman council in the district in which the facility is located to discuss residents’ experiences within the facility. (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 aclass IJ or class II violation, or more than three uncorrected class III violations. (d) The agency may conduct periodic followup inspections as necessary to monitor the compliance of facilities with a history of any class I, class II, or class III violations that threaten the health, safety, or security of residents. (e) The agency may conduct complaint investigations as warranted to investigate any allegations of noncompliance with requirements required under this part or rules adopted under this part. (4) The facility shall not hamper or prevent residents from exercising their rights as specified in this section. § 429.28, Fla. Stat. (2018). 23. Under Florida law, (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. * * * (g) In addition to the requirements of Section 429.41(1)(k), F.S., the use of physical restraints by a facility must be reviewed by the resident’s physician annually. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical restraint. Fla. Admin. Code R. 58A-5.0182(6)(g) (2018). 24. Under Florida law, (k) The use of physical or chemical restraints. The use of physical restraints is limited to half-bed rails as prescribed and documented by the resident’s physician with the consent of the resident or, if applicable, the resident’s representative or designee or the resident’s surrogate, guardian, or attorney in fact. $429.41(1)(k), Fla. Stat. (2018). Facts 25. A standard biennial survey of Respondent’s facility was conducted on June 7th, 2017. 26. Based on observation, record review, and interview, the Respondent failed to have a consent for the use of bed rails for one out of ten sampled residents. 27. On 06/07/17 at 8:06 AM, the Agency observed that Resident #1 rested on a bed with a full bed rail up. 28. Review of Resident #1's record revealed that no consent for the use of the full bed rail. The doctor from hospice order full bed rails for safety on 04/06/17. 29. In an interview on 06/07/17 at 2:15 PM, Staff Member B stated that she was not able to find the Resident’s written consent. 30. The Respondent was cited for a class II violation. 31. A standard biennial survey revisit of Respondent’s facility was conducted on 08/31/17. 32. Based on observation, record review, and interview, the Respondent failed to have a consent for the use of bed rails for one out of twelve sampled residents. 33. On 08/31/17, during tour of the facility at approximately 8:43 AM, the Agency observed Resident #12 in bed with half side rails up. 34. Review of Resident #12's record revealed no consent for the use of side rails. 35. Staff B stated, "The resident is under guardianship program and the consent was sent to them to be signed on 07/26/17 and had not been sent back; I call them every week and still did not receive it." 36. | The Respondent was cited for an uncorrected class [II violation. Sanction 37. 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. § 429.14(1), Fla. Stat. (2018). 38. Under Florida law, violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. Violations shall be classified on the written notice as follows: Class “II” 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. A citation for a class III 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. (2018). 39. 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)(c), Fla. Stat. (2018). 40. The Agency cited the Respondent for a Class II violation in accordance with applicable statutes and authorizing rules and it remained uncorrected for the following survey. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500 against the Respondent. COUNT I Continued Residency—Health Assessment 41. The Agency re-alleges and incorporates by reference paragraphs 1-2 and Counts 1-I] as if fully set forth herein. 42. Section 429.26, Florida Statutes, states in pertinent part: (1) The owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident’s family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Families, the administrator must notify the appropriate contact person in the applicable department. § 429.26(1), Fla. Stat. (2018). 43. Rule 58A-5.0181, Florida Administrative Code, states in pertinent part: (1) ADMISSION CRITERIA. (a) An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: 14. Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator must base the decision on: a. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, F.S., and subsection (2) of this rule; Fla. Admin. Code R. 58A-5.0181(1)(a) (2018). 44. Rule 58A-5.0181, Florida Administrative Code, states in pertinent part: (2) HEALTH ASSESSMENT. As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a health care provider as specified in either paragraph (a) or (b), of this subsection. (a) A medical examination completed within 60 calendar days before to the individual’s admission to a facility pursuant to Section 429.26(4), F.S. The examination must address the following: 1. The physical and mental status of the resident, including the identification of any health-related problems and functional limitations, 2. An evaluation of whether the individual will require supervision or assistance with the activities of daily living, 3. Any nursing or therapy services required by the individual, 4. Any special diet required by the individual, 5. A list of current medications prescribed, and whether the individual will require any assistance with the administration of medication, 6. Whether the individual has signs or symptoms of Tuberculosis, Methicillin Resistant Staphylococcus Aureus, Scabies or any other communicable disease, which are likely to be transmitted to other residents or staff, 7. A statement on the day of the examination that, in the opinion of the examining health care provider, the individual’s needs can be met in an assisted living facility; and, 8. The date of the examination, and the name, signature, address, telephone number, and license number of the examining health care provider. The medical examination may be conducted by a health care provider licensed under Chapter 458, 459 or 464, F.S. (b) A medical examination completed after the resident’s admission to the facility within 30 calendar days of the admission date. The examination must be recorded on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, October 2010. The form is hereby incorporated by reference. AHCA Form 1823 may be obtained http://www.flrules.org/Gateway/reference.asp?No=Ref-04006. Faxed or electronic copies of the completed form are acceptable. The form must be completed as instructed. 1. Items on the form that may have been omitted by the health care provider during the examination do not necessarily require an additional face-to-face examination for completion. The facility may obtain the omitted information either orally or in writing from the health care provider. 2. Omitted information must be documented in the resident’s record. Information received orally must include the name of the health care provider, the name of the facility staff recording the information, and the date the information was provided. 3. Electronic documentation may be used in place of completing the section on AHCA Form 1823 referencing Services Offered or Arranged by the Facility for the Resident. The electronic documentation must include all of the elements described in this section of AHCA Form 1823. * * * (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (ec) of this subsection, criteria for continued residency in any licensed facility must be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in Rule 58A-5.0131, F.A.C. The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference in paragraph (2)(b) of this rule. The form must be completed in accordance with that paragraph. (a) The resident may be bedridden for up to 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore may be retained provided that: 1. The resident contracts directly with a licensed home health agency or a nurse to provide care, or the facility has a limited nursing services license and services are provided pursuant to a plan of care issued by a health care provider; 2. The condition is documented in the resident’s record; and 3. If the resident’s condition fails to improve within 30 days, as documented by a health care provider, the resident must be discharged from the facility. (c) A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to the services of a licensed hospice that coordinates and ensures the provision of any additional care and services that may be needed; 2. Continued residency is agreeable to the resident and the facility; 3. An interdisciplinary care plan, which specifies the services being provided by hospice and those being provided by the facility, is developed and implemented by a licensed hospice in consultation with the facility; and 4. Documentation of the requirements of this paragraph is maintained in the resident’s file. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility at all times. (e) A hospice resident that meets the qualifications of continued residency pursuant to this subsection may only receive services from the assisted living facility’s staff within the scope of the facility’s license. (f) Assisted living facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living for residents admitted to hospice; however, staff may not exceed the scope of their professional licensure or training. (g) Continued residency criteria for facilities holding an extended congregate care license are described in Rule 58A-5.030, F.A.C. 11 Fla. Admin. Code R. 58A-5.0181(2) & (4) (2018). 45. Under Florida law, (32) “Significant Change” means a sudden or major shift in behavior or mood inconsistent with the resident’s diagnosis, or a deterioration in health status such as unplanned weight change, stroke, heart condition, enrollment in hospice, or stage 2, 3 or 4 pressure sore. Ordinary day-to-day fluctuations in functioning and behavior, a short-term illness such as a cold, or the gradual deterioration in the ability to carry out the activities of daily living that accompanies the aging process are not considered significant changes. Fla. Admin. Code R. 58A-5.0131(32) (2018). Facts 46. Based on record review and interview during the June 7, 2017 survey, the Respondent failed to update the health assessments (AHCA form 1823) for two out of 10 sampled residents who were admitted to hospice services. 47. Resident #1's health assessment (AHCA form 1823) completed on 03/10/17 did not show a hospice admission diagnosis nor that the Resident received hospice services. 48. Review of Resident #1's record revealed the admission date to hospice services was on 03/20/17 with a diagnosis of heart failure. 49. Resident #2's health assessment (AHCA form 1823) completed on 02/01/17 did not show a hospice admission diagnosis nor that the Resident received hospice services. 50. Review of Resident #2's record revealed the admission date to hospice services was on 09/11/16 with diagnosis of Alzheimer's disease. 51. In an interview on 06/07/17 at 1:35 PM, Staff Member B confirmed that Residents #1 and #2 received hospice services. 12 52. The Respondent was cited with a class III violation. 53. Based on observation, record review, and interview during the August 31 revisit, the facility failed to update the health assessments for one of twelve sampled residents. 54. On 08/31/17 at 9:14 AM, the Agency observed Staff I giving coffee to Resident #11 with a spoon into the resident's month. 55. On 08/31/17 at 9:15 AM, Staff D stated that Resident # 11 needed to be fed and staff had to administer medications to the resident. Staff D stated, "He became like that since Saturday and they said that they were going to place him on continuous care, but they did not." 56. Review of Resident #11's record revealed that he was admitted to hospice on 08/23/17. A new health assessment was completed by his physician on 08/24/17. The health assessment was missing the resident's name in every page and was missing the height and weight. The activities of daily living (ADLs) section stated that he was independent with ambulation and transferring, required assistance with eating and total assistance with the rest of his ADLs. The assessment also stated that he required assistance with self-administration of medications. 57. On 08/31/17 at 10:05 AM Staff D attempted to make Resident #11 stand up and the resident was not able; she stated, "Maybe when he is more awake because this morning he walked a few steps." 58. The Respondent was cited for an uncorrected class III violation. Sanction 59. 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. § 429.14(1), Fla. Stat. (2018). 60. Under Florida law, violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. Violations shall be classified on the written notice as follows: 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. A citation-for a class III violation must specify the time within which the violation is required to be corrected. If a class IJI violation is corrected within the time specified, a fine may not be imposed. § 408.813(2)(c), Fla. Stat. (2018). 61. Under Florida law, the agency shall impose an administrative fine for a cited class II violation in an amount not less than $500 and not exceeding $1,000 for each violation. § 429.19(2)(c), Fla. Stat. (2018). 62. The Agency cited the Respondent for a Class III violation in accordance with applicable statutes and authorizing rules and it remained uncorrected. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative $500 against the Respondent. COUNT IV Survey Fee 63. Under Florida law: (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. § 429.19(7) Fla. Stat. (2018). 64. | The Agency re-alleges and incorporates by reference all of the facts listed in Counts I through II of this Administrative Complaint. 65. In response to a complaint, the Agency conducted a complaint survey of the Respondent’s facility. 66. As aresult of the complaint survey, the Respondent was cited for violations. 67. The basis for the violations alleged in this Administrative Complaint arise from the initial complaint and survey. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to assess a survey fee of $458.75 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully Submitted, WL. Antonio, Lozada, Assistant General Counsel Florida Bar No. 112613 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3699 Facsimile (850) 922-9634 Email: Antonio.Lozada@ahca.myflorida.com NOTICE 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) 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. 16 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this day of July, 2018. i { Antonio Lozada, Assistant General Counsel Florida Bar No. 112613 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3699 Facsimile (850) 922-9634 Email: Antonio.Lozada@ahca.myflorida.com Keisha Woods, Unit Manager Assisted Living Facility Unit Agency for Health Care Administration (Electronic Mail) Administrator Villa Serena II 60 NW 33rd Ave Miami, FL 33125 Arlene Mayo-Davis, Field Office Manager Agency for Health Care Administration (Electronic Mail) Roxana Solano, President/Registered Agent Villa Serena II 754 NW 22nd Court MIAML, FL 33125 (Certified Mail) (Certified Mail) quay gogo oo27 bO4b 818? 73 9469 OOF0 O02? bO4b 618? 80 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Villa Serena II ACHA No. 2018003250 2017011855 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but_must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (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 form 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 fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. | understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged 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 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. Licensee Name: 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 form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 9489009000276046818780 Status Label Created, not yet in system A status update is not yet available on your package. It will be available when the shipper provides an update or the package is delivered to USPS. Check back soon. Sign up for Informed Delivery® to receive notifications for packages addressed to you. Label Created, not yet in system USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 9489009000276046818773 Status Label Created, not yet in system A status update is not yet available on your package. It will be available when the shipper provides an update or the package is delivered to USPS. Check back soon. Sign up for Informed Delivery® to receive notifications for packages addressed to you. Label Created, not yet in system

Docket for Case No: 18-004559