STATE OF FLORIDA NOV AGENCY FOR PERSONS WITH DISABILITIES AP gerics cove Office AGENCY FOR PERSONS WITH DISABILITIES, Petitioner, v. License Number: 10-2999GH CARE AMBASSADORS GROUP HOME, OWNED AND OPERATED BY CARE AMBASSADORS, LLC, Respondent. / ADMINISTRATIVE COMPLAINT The AGENCY FOR PERSONS WITH DISABILITIES (“Agency”) issues this Administrative Complaint against Care Ambassadors Group Home, owned and operated by Care Ambassadors, LLC, (“Respondent”) and states the following as the basis for this complaint: 1: Petitioner is the state agency charged with regulating the licensing and operation of foster care facilities, group home facilities, residential habilitation centers, and comprehensive transitional education programs pursuant to section 20.197 and Chapter 393, Florida Statutes. 2: At all times material to this complaint, Respondent has held a group home facility license issued by the Agency for the followmg address: 3501 N. 30” Terrace, Hollywood, Florida 33021. Ae Pursuant to the Florida Division of Corporations, David Maseda is listed as the sole managing member of Care Ambassadors, LLC, a Florida Limited Liability Corporation. 4. Section 393.0673, Florida Statutes, sets forth the Agency’s authority for denial, suspension, or revocation of license; moratorium on admissions; and administrative 10. fines. (1) The agency may revoke or suspend a license or impose an administrative fine, not to exceed $1,000 per violation per day, if: (a) The licensee has: 1. Falsely represented or omitted a material fact in its license application submitted under s. 393.067; 2. Had prior action taken against it under the Medicaid or Medicare program; or 3. Failed to comply with the applicable requirements of this chapter or rules applicable to the licensee. On or about August 21, 2018, David Maseda, Managing Member of Care Ambassadors, LLC, submitted an initial facility licensure application for a home located at 3501 N. 30" Terrace, Hollywood, Florida 33021. On the Agency facility license application form, Section TV, Additional Documentation, item #4 requires “Documentation that the facility has been inspected by the local fire safety authority or the State Fire Marshal and determined to be in compliance with applicable statutes and rules.” Section V, Affidavit, of the Agency facility license application form states “Under penalty of perjury, I hereby attest that all information contained in and submitted with application is true and accurate to the best of my knowledge and by submitting same I am requesting a license to operate a facility in accordance with Chapter 393, F.S. I also attest that I have the authority to attest to such information on behalf of the above-named applicant for licensure or license renewal.” On the initial facility license application for Care Ambassadors group home submitted to the Agency, David Maseda attested that the information submitted with the application was true and accurate, as indicated by his notarized signature. The fire inspection report ostensibly submitted as part of the imitial facility application package by David Maseda was dated July 2, 2018. The name and signature of the inspector on the report is Lieutenant Daniel Suarez with Broward Sheriff's Office Fire Rescue. The report for property address 3501 N. 30" Terrace, Hollywood, states “A certificate of use fire inspection of your occupancy revealed no violations at the time of this inspection.” A satisfactory inspection by the local authority having jurisdiction over fire safety is required for initial licensure and annual license renewals. Fla. Admin. Code R. 65G-2.010(2); 69A-38.036. ii. 12. 14. 15. Lz 18. The Agency issued an initial one-year group home facility license for Care Ambassadors Group Home at 3501 N. 30” Terrace, Hollywood, effective November 1, 2018. On or about August 15, 2019, David Maseda, managing member of Care Ambassadors, LLC, submitted a renewal facility licensure application for the group home located at 3501 N. 30" Terrace, Hollywood, Florida 33021. The fire inspection report ostensibly submitted as part of the renewal facility application package by David Maseda was dated January 14, 2019. The name and signature of the inspector on the report is Lieutenant Daniel Suarez with Broward Sheriffs Office Fire Rescue. The report for property address 3501 N. 30" Terrace, Hollywood, states “A certificate of use fire mspection of your occupancy revealed no violations at the time of this inspection.” On or about August 22, 2019, the Agency received written confirmation from David Zipoli, Fire Inspector with Broward Sheriff's Office Fire Rescue, that the property located at 3501 N. 30" Terrace, Hollywood, was not inspected by Broward Sheriff's Office Fire Rescue. He stated that the report submitted by Care Ambassadors, LLC for that address was not one of Broward Fire Rescue’s fire inspections and that the city of Hollywood conducts their own fire inspections. On or ahout August 26, 2019, the Agency received written confirmation from Deputy Fire Marshal/Battalion Chief Jorge Castano, with the City of Hollywood Fire Rescue and Beach Safety, confirming that the property located at 3501 N, 30% Terrace, Hollywood, was never issued an approved fire inspection report by the City of Hollywood. The issuance of a license does not constitute a waiver of any statutory or rule violations by the licensee and does not prevent the Agency from seeking administrative sanctions against the licensee for violations that occurred during the term of previous licenses, up to a period of two years, for the same facility. Fla. Admin. Code R. 65G-2.003(6). The Agency may revoke a license if the licensee has falsely represented or omitted a material fact in its license application. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated section 393.0673, Florida Statutes, by subinitting falsified fire inspection reports to the Agency. Based on the foregoing and pursuant to 393.0673, Florida Statutes, the Agency requests that a Final Order be entered that revokes the Respondent’s license. Dated November 7, 2019 Trevor Suter, Esq. Senior Attorney Agency for Persons with Disabilities 4030 Esplanade Way, Suite 380 Tallahassee, Florida 32399-0950 Attachments: Notice of Administrative Hearing Rights Copies furnished to: David Maseda Rita Castor Care Ambassadors, LLC Regional Operations Manager 3501 N. 30™ Terrace APD Southeast Region Hollywood, Florida 33021 Notice of Administrative Hearing Rights For Administrative Complaint You have the right to request a hearing to be conducted in accordance with sections 120.569 and 120.57, Florida Statutes (F.S.), and to be represented by counsel or qualified representative to challenge the administrative complaint. To obtain an administrative hearing, you must file a written request for hearing with the Agency Clerk by 5:00 PM Eastern Time within 21 days of the day that you receive the administrative complaint. Filed with the Agency Clerk means received by the Agency Clerk’s Office. If you fail to file the request for hearing within the 21 days, you waive the right to have a hearing. The request for hearing shall include: 1. Your name, address, e-mail address, telephone number, and facsimile number, if any, if you are not represented by an attorney or a qualified representative; 2. The name, address, e-mail address, telephone number, and facsimile number of your attorney or qualified representative, 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. (Pursuant to sections 120.569 and 120.57, F.S., a disputed issue of material fact entitles you to a formal hearing; if there are no disputed issues of material fact then you are entitled to an informal hearing); 4. A statement of when you received notice of the administrative complaint; and 5. A statement including the file number on the administrative complaint. You must file your request for hearing with the Agency Clerk by hand delivery, express delivery service, U.S. mail, facsimile transmission, or by email at the following address: Agency for Persons with Disabilities Attention: Agency Clerk Filed with the Agency Clerk means received in 4030 Esplanade Way, Suite 335 the Office of Agency Clerk by 5:00 pm on the Tallahassee, FL 32399 due date. APD.AgencyClerk@apdcares.org (850) 921-3779 (phone) Mediation under s.120.573, Florida Statutes, is (850) 410-0665 (fax) not available for this proceeding. Rev. OGC May 19, 2017

Docket for Case No: 20-000001FL