AHCA acy CLERK STATE OF FLORIDA AGENCY CL AGENCY FOR HEALTH CARE ADMINISTRATI@) wAY 30 Pt: 22 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. AHCA No. 2019005632 CRISTAL PALACE RESORT PB LLC, Respondent. / FINAL ORDER Having reviewed the Notice of Intent to Impose Fine and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency issued the Respondent the attached Notice of Intent and Election of Rights form by both mail and electronic mail. (Ex. 1) The Election of Rights form advised of the right to an administrative hearing pursuant to Sections 120.57(1) and 120.57(2), Florida Statutes. The Respondent failed to timely file the Election of Rights form or other response with the Agency Clerk. 2. By failing to timely respond, the Respondent waived the right to a hearing and waived the right to contest the allegations within the Notice of Intent. Cann v. Department of Children and Family Services, 813 So.2d 237 (Fla. 2d DCA 2002). The findings of fact, conclusions of law and proposed sanction set forth within the Notice of Intent are adopted and incorporated by reference. Based upon the foregoing, it is ORDERED: 3. The Respondent shall pay the Agency $500.00. If full payment has already been made, the cancelled check is your receipt and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. A check payable to the “Agency for Health Care Administration” and containing the AHCA case number should be sent to: Central Intake Unit Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 61 Tallahassee, Florida 32308 » 2019. ORDERED at Tallahassee, Florida, on this 2e day of AG Qn ayhew, Secretary cy for Health Care Administration NOTICE OF RIGHT TO JUDICIAL REVIEW A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct apy of this Final Order was served on the below-named persons by the method designated on this _¥0“day of or , 2019, Oop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 Telephone: (850) 412-3630 Facilities Intake Unit Agency for Health Care Administration (Electronic Mail) Central Intake Unit Agency for Health Care Administration (Electronic Mail) Georgianna Powers, Administrator Cristal Palace Resort PB LLC 1881 Palm Bay Rd. Palm Bay, Florida 32905 (U.S. Mail) Q0l Foo S632. RON DESANTIS GOVERNOR MARY C. MAYHEW SECRETARY April 12, 2019 EMAILED AND MAILED Georgianna Powers, Administrator File Number: 11968825 Cristal Palace Resort Pb Llc License Number: 12660 1881 Palm Bay Rd Provider Type: Assisted Living Facility Palm Bay, FL 32905 RE: 2019005632, 1881 Palm Bay Rd, Palm Bay NOTICE OF INTENT TO IMPOSE FINE (15-Day Full Report) Pursuant to Section 408.813(3)(b), Florida Statues (F.S.), a fine of $500 is imposed on the licensee due to the untimely submission of an adverse incident report to the Agency. Section 429.23(4), F.S., states that each assisted living facility shall provide within 15 days, a full report to the Agency on all adverse incidents specified in Section 429.23, F.S. The full report must include the results of the facility’s investigation into the adverse incident. Based upon the date of occurrence indicated in the full report submitted to the Agency by the licensee, the full report was required to be submitted to the Agency on or before July 25, 2017 but was not received until December 04, 2018, making the report late. 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 requesting an administrative hearing 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 that the Notice of Intent is 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 by the 21st day, the right to a hearing will be waived. The Agency Clerk’s office can be reached by telephone at (850) 412-3630 or by facsimile at (850) 921-0158. The Election of Rights form shall be addressed to: Agency Clerk RECEIVELD Agency for Health Care Administration GENERAL COUNSEL 2727 Mahan Drive; MS 3 ape 15 2019 Tallahassee, FL 32308 Agency for Health Care Administration shat EXHIBIT 14 DiuUGeEe 2727 Mahan Drive * MS#30 Tallahassee, FL 32308 AHCA.MyFlorida.com Cristal Palace Resort Pb Llc April 12, 2019 Page 2 Any party who appears in an Agency proceeding has the right, at the party’s 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. PLEASE SEE THE ATTACHED ELECTION OF RIGHTS FORM. If you have any questions or need further assistance, please call Sean Massey at (850) 412-3759 or (850) 412-3731 or e-mail at sean.massey@ahca.myflorida.com. Sean Massey, Program Administrator Office of Risk Management and Patient Safety Agency for Health Care Administration cc: Legal Intake Unit, Mail Stop 3 Enforcement Unit, Mail Stop 26 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Cristal Palace Resort Pb Llc Complaint Number: 2019005632 ELECTION OF RIGHTS This Election of Rights form is attached to the Notice of Intent. The Election of Rights form 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 Notice of Intent. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day that you received the Notice of Intent, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the fine alleged in the Notice of Intent. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, 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 waive the right to a hearing to contest the allegations of fact and conclusions of law alleged in the Notice of Intent. | understand that by waiving the right to a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Notice of Intent and imposes the fine sought in the Notice of Intent. OPTION TWO (2) I admit the allegations of fact alleged in the Notice of Intent, 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 fine is too severe and should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Notice of Intent 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 request for hearing in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. The request for hearing must be received by the Agency Clerk at the address above within 21 days of your receipt of this Notice of Intent. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: (a) The name, address, any e-mail address, telephone number, and facsimile number, if any, of the respondent, if the respondent is not represented by an attorney or qualified representative. (b) The name, address, e-mail 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. (c) A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. (d) A statement of when the respondent received notice of the administrative complaint. (e) 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 Address:

Docket for Case No: 20-002673