STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 2020 APR 28 A i Ol Petitioner, AHCA No. 2019002618 v. 2019003909 2019004301 BOBILYN DUNCAN d/b/a PRESTIGE PLACE ALF, Respondent. / FINAL ORDER Having reviewed the Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The Election of Rights form advised Respondent of its right to an administrative hearing. The Respondent received the Administrative Complaint and Election of Rights form, (Ex. 2), but failed to timely file the Election of Rights form or other hearing request with the Agency Clerk. The Respondent thus waived the right to a hearing to contest the allegations and sanction sought in the Administrative Complaint. Cann v. Dep’t of Child. & Fam. Servs., 813 So. 2d 237 (Fla. 2d DCA 2002). Based upon the foregoing, it is ORDERED: 2. The findings of fact and conclusions of law set forth in the Administrative Complaint are adopted and incorporated by reference into this Final Order. 3. The Respondent shall pay the Agency $9,500.00 in administrative fines and $388.75 in survey fees, for a total payment of $9,888.75. If full payment has been made, the cancelled check acts as receipt of payment 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 made payable to the “Agency for Health Care Administration” and containing the AHCA ten-digit case number should be sent to: Central Intake Unit Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 61 Tallahassee, Florida 32308 ORDERED at Tallahassee, Florida, on this Mary 'C. Mayhew, Secretary Agency 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 persons by the method designated on this y of this Final Order was served on the below-named ZERO Tol Alp , 2020. Richard J. Shoop, 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) Michael Roscoe, Senior Attorney Office of the General Counsel Agency for Health Care Administration (Electronic Mail) Bobsilyn Duncan, Administrator Bobsilyn Duncan d/b/a Prestige Place ALF 256 Barbarossa Road Palm Bay, Florida 32907 (U.S. Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No: 2019002618 2019003909 vs. 2019004301 License No. 12968 BOBSILYN DUNCAN d/b/a PRESTIGE Facility Type: ALF PLACE ALF, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Bobsilyn Duncan d/b/a Prestige Place ALF (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2019), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of nine thousand five hundred dollars ($9,500.00) based upon ‘one Class II deficient practice, three (3) uncorrected Class III deficient practices, and four (4) unclassified deficient practices, in addition to survey fees in the amount of three hundred eighty-eight dollars and seventy-five cents ($388.75), for the sum of nine thousand eight hundred eighty-eight dollars and seventy-five cents ($9,888.75). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2019). EXHIBIT 1 2. Venue lies pursuant to Rule 28-106.207 of the Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent operates a six (6) bed assisted living facility located at 256 Barbarossa Road, Palm Bay, Florida 32907, and is licensed as an assisted living facility, license number 12968. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Rule 58A-5.036 of the Florida Administrative Code provides: (1) DETAILED EMERGENCY ENVIRONMENTAL CONTROL PLAN. Each assisted living facility shall prepare a detailed plan (“plan”) to serve as a supplement to its Comprehensive Emergency Management Plan, to address emergency environmental which includes the following information: (a) The acquisition of a sufficient alternate power source such as a generator(s), maintained at the assisted living facility, to ensure that current licensees of assisted living facilities will be equipped to ensure ambient air temperatures will be maintained at or below 81 degrees Fahrenheit for a minimum of ninety-six (96) hours in the event of the loss of primary electrical power. 1. The required temperature must be maintained in an area or areas, determined by the assisted living facility, of sufficient size to maintain residents safely at all times and that is appropriate for resident care needs and life safety requirements. For planning purposes, no less than twenty (20) net square feet per resident must be provided. The assisted living facility may use eighty percent (80%) of its licensed bed capacity as the number of residents to be used in the calculation to determine the required square footage. This may include areas that are less than the entire assisted living facility if the assisted living facility’s comprehensive emergency management plan includes allowing a resident to congregate when he or she desires in portions of the building where temperatures will be maintained and includes procedures for monitoring residents for signs of heat related injury as required by this rule. This rule does not prohibit a facility from acting as a receiving provider for evacuees when the conditions stated in section 408.821, F.S., and subsection 58A-5.026(5), F.A.C., are met. The plan shall include information regarding the area(s) within the assisted living facility where the required temperature will be maintained. 2. The alternate power source and fuel supply shall be located in an area(s) in accordance with local zoning and the Florida Building Code. 3. Each assisted living facility is unique in size; the types of care provided; the physical and mental capabilities and needs of residents; the type, frequency, and amount of services and care offered; and staffing characteristics. Accordingly, this rule does not limit the types of systems or equipment that may be used to achieve ambient temperatures at or below 81 degrees Fahrenheit for a minimum of ninety-six (96) hours in the event of the loss of primary electrical power. The plan shall include information regarding the systems and equipment that will be used by the assisted living facility and the fuel required to operate the systems and equipment. a. An assisted living facility in an evacuation zone pursuant to chapter 252, F.S., must maintain an alternative power source and fuel as required by this subsection at all times when the assisted living facility is occupied but is permitted to utilize a mobile generator(s) to enable portability if evacuation is necessary. b. Assisted living facilities located on a single campus with other facilities under common ownership, may share fuel, alternative power resources, and resident space available on the campus if such resources are sufficient to support the requirements of each facility’s residents, as specified in this rule. Details regarding how resources will be shared and any necessary movement of residents must be clearly described in the emergency power plan. c. A multistory facility, whose comprehensive emergency management plan is to move residents to a higher floor during a flood or surge event, must place its alternative power source and all necessary additional equipment so it can safely operate in a location protected from flooding or storm surge damage. (b) The acquisition of sufficient fuel, and safe maintenance of that fuel at the facility, to ensure that in the event of the loss of primary electrical power there is sufficient fuel available for the alternate power source to maintain ambient temperatures at or below 81 degrees Fahrenheit for a minimum of ninety-six (96) hours after the loss of primary electrical power during a declared state of emergency. The plan must include information regarding fuel source and fuel storage. 1. Facilities must store minimum amounts of fuel onsite as follows: a. A facility with a licensed capacity of 16 beds or less must store 48 hours of fuel onsite. b. A facility with a licensed capacity of 17 or more beds must store 72 hours of fuel onsite. 2. An assisted living facility located in an area in a declared state of emergency area pursuant to section 252.36, F.S., that may impact primary power delivery must secure ninety-six (96) hours of fuel. The assisted living facility may utilize portable fuel storage containers for the remaining fuel necessary for ninety-six (96) hours during the period of a declared state of emergency. 3. Piped natural gas is an allowable fuel source and meets the onsite fuel supply requirements under this rule. 4. If local ordinances or other regulations limit the amount of onsite fuel storage for the assisted living facility’s location, then the assisted living facility must develop a plan that includes maximum onsite fuel storage allowable by the ordinance or regulation and a reliable method to obtain the maximum additional fuel at least 24 hours prior to depletion of onsite fuel. (c) The acquisition of services necessary to maintain, and test the equipment and its functions to ensure the safe and sufficient operation of the alternate power source maintained at the assisted living facility. (d) The acquisition and maintenance of a carbon monoxide alarm. (2) SUBMISSION OF THE PLAN. (a) Each assisted living facility licensed prior to the effective date of this rule shall submit its plan to the local emergency management agency for review within 30 days of the effective date of this rule. Assisted living facility plans previously submitted and approved pursuant to emergency rule SSAER17-1, F.A.C., will require resubmission only if changes are made to the plan. (b) Each new assisted living facility shall submit the plan required under this rule prior to obtaining a license. (c) Each existing assisted living facility that undergoes any additions, modifications, alterations, refurbishment, renovations or reconstruction that require modification of its systems or equipment affecting the facility’s compliance with this rule shall amend its plan and submit it to the local emergency management agency for review and approval. (3) APPROVED PLANS. (a) Each assisted living facility must maintain a copy of its approved plan in a manner that makes the plan readily available at the licensee’s physical address for review by a legally authorized entity. If the plan is maintained in an electronic format, assisted living facility staff must be readily available to access and produce the plan. For purposes of this section, “readily available” means the ability to immediately produce the plan, either in electronic or paper format, upon request. (b) Within two (2) business days of the approval of the plan from the local emergency management agency, the assisted living facility shall submit in writing proof of the approval to the Agency for Health Care Administration. (c) The assisted living facility shall submit a consumer-friendly summary of the emergency power plan to the Agency. The Agency shall post the summary and notice of the approval and implementation of the assisted living facility emergency power plans on its website within ten (10) business days of the plan's approval by the local emergency management agency and update within ten (10) business days of implementation. (4) IMPLEMENTATION OF THE PLAN. (a) Each assisted living facility licensed prior to the effective date of this rule shall, no later than June 1, 2018, have implemented the plan required under this rule. (b) The Agency shall allow an extension up to January 1, 2019 to providers in compliance with subsection (c), below, and who can show delays caused by necessary construction, delivery of ordered equipment, zoning or other regulatory approval processes. Assisted living facilities shall notify the Agency that they will utilize the extension and keep the Agency apprised of progress on a quarterly basis to ensure there are no unnecessary delays. If an assisted living facility can show in its quarterly progress reports that unavoidable delays caused by necessary construction, delivery of ordered equipment, zoning or other regulatory approval processes will occur beyond the initial extension date, the assisted living facility may request a waiver pursuant to section 120.542, F.S. (c) During the extension period, an assisted living facility must make arrangements pending full implementation of its plan that provides the residents with an area or areas to congregate that meets the safe indoor air temperature requirements of paragraph (1)(a), for a minimum of ninety-six (96) hours. 1. An assisted living facility not located in an evacuation zone must either have an alternative power source onsite or have a contract in place for delivery of an alternative power source and fuel when requested. Within twenty-four (24) hours of the issuance of a state of emergency for an event that may impact primary power delivery for the area of the assisted living facility, it must have the alternative power source and no less than ninety-six (96) hours of fuel stored onsite. 2. An assisted living facility located in an evacuation zone pursuant to chapter 252, F.S., must either: a. Fully and safely evacuate its residents prior to the arrival of the event, or b. Have an alternative power source and no less than ninety-six (96) hours of fuel stored onsite, within twenty-four (24) hours of the issuance of a state of emergency for the area of the assisted living facility. (d) Each new assisted living facility shall implement the plan required under this rule prior to obtaining a license. (e) Existing assisted living facilities that undergo any additions, modifications, alterations, refurbishment, renovations or reconstruction that require modification of the systems or equipment affecting the assisted living facility’s compliance with this rule shall implement its amended plan concurrent with any such additions, modifications, alterations, refurbishment, renovations or reconstruction. (f) The Agency for Health Care Administration may request cooperation from the State Fire Marshal to conduct inspections to ensure implementation of the plan in compliance with this rule. (5) POLICIES AND PROCEDURES. (a) Each assisted living facility shall develop and implement written policies and procedures to ensure that the assisted living facility can effectively and immediately activate, operate and maintain the alternate power source and any fuel required for the operation of the alternate power source. The procedures shall ensure that residents do not experience complications from fluctuations in ambient air temperatures inside the facility. Procedures must address the care of residents occupying the facility during a declared state of emergency, specifically, a description of the methods to be used to mitigate the potential for heat related injury including: 1. The use of cooling devices and equipment; 2. The use of refrigeration and freezers to produce ice and appropriate temperatures for the maintenance of medicines requiring refrigeration; 3. Wellness checks by assisted living facility staff to monitor for signs of dehydration and heat injury; and, 4. A provision for obtaining medical intervention from emergency services for residents whose life safety is in jeopardy. 8. (b) Each assisted living facility shall maintain the written policies and procedures in a manner that makes them readily available at the licensee’s physical address for review by a legally authorized entity. If the policies and procedures are maintained in an electronic format, assisted living facility staff must be readily available to access the policies and procedures and produce the requested information. For purposes of this section, “readily available” means the ability to immediately produce the policies and procedures, either in electronic or paper format, upon request. (c) The written policies and procedures must be readily available for inspection by each resident; each resident’s legal representative, designee, surrogate, guardian, attorney in fact, or case manager; each resident’s estate; and such additional parties as authorized in writing or by law. (6) REVOCATION OF LICENSE, FINES OR SANCTIONS. For a violation of any part of this rule, the Agency for Health Care Administration may seek any remedy authorized by chapter 429, Part I, F.S., or chapter 408, Part II, F.S., including, but not limited to, license revocation, license suspension, and the imposition of administrative fines. (7) COMPREHENSIVE EMERGENCY MANAGEMENT PLAN. (a) Assisted living facilities whose comprehensive emergency management plan is to evacuate must comply with this rule. (b) Each facility whose plan has been approved shall submit the plan as an addendum with any future submissions for approval of its comprehensive emergency management plan. (8) NOTIFICATION. (a) Within five (5) business days, each assisted living facility must notify in writing, unless permission for electronic communication has been granted, each resident and the resident’s legal representative: 1. Upon submission of the plan to the local emergency management agency that the plan has been submitted for review and approval; 2. Upon final implementation of the plan by the assisted living facility. (b) Each assisted living facility must maintain a copy of each notification set forth in paragraph (a), above, in a manner that makes each notification readily available at the licensee’s physical address for review by a legally authorized entity. If the notifications are maintained in an electronic format, facility staff must be readily available to access and produce the notifications. For purposes of this section, “readily available” means the ability to immediately produce the notifications, either in electronic or paper format, upon request. On or about September 26, 2018, the Agency conducted a complaint investigation survey (#2018009556) of Respondent’s facility. 9. Based upon interviews by the Agency’s representative, Respondent failed to maintain a copy of its Emergency Power Plan (“EPP”) at the facility, failed to acquire services to maintain and test its alternate power sources, failed to have a process necessary to maintain and test its alternate power source, failed to develop written policies and procedures to ensure that the facility would effectively and immediately operate and maintain the alternate power source and any fuel required for the operation of the alternate power source, failed to have a plan to obtain additional fuel in an emergency, failed to acquire carbon monoxide alarms, and failed to notify the residents or their legal representatives in writing within five days of submitting its EPP to the local emergency management agency for review and approval, the same being contrary to the mandates of law. 10. On or about September 25, 2018, at 4:00 p.m., the Agency’s representative reviewed Florida’s Health Finder website and noted that Respondent’s EPP was approved on September 28, 2017 and was implemented on September 20, 2017. 11. On or about September 26, 2018, at 9:55 a.m., the Agency’s representative requested to review Respondent’s EPP and EPP approval letter from the local emergency management agency. 12. On or about September 26, 2018, at 10:01 a.m., the Agency’s representative interviewed Respondent’s Administrator and requested to review Respondent’s EPP and EPP approval letter, but Respondent’s Administrator informed the Agency’s representative that Respondent’s EPP and approval letter were at the home of a consultant who was updating Respondent’s plan. 13. The Agency’s representative gave Respondent the opportunity to retrieve Respondent’s EPP from its consultant, but Respondent’s Administrator was not able to obtain the EPP from its consultant by the end of the survey. 14. On or about September 26, 2018, at 12:00 p.m., the Agency’s representative toured Respondent’s facility and noted that there was an unboxed eight-thousand watt portable generator and a six-gallon filled gasoline container in Respondent’s garage. 15. The Agency’s representative interviewed Respondent’s Administrator who stated the following: a. the portable generator and the gas container that the Agency’s representative located in Respondent’s garage were the facility’s alternate power source and fuel to be used in the event of an emergency; the Administrator did not know how much gas would be needed in the event of the loss of primary electrical power, to ensure that there would sufficient fuel available to maintain ambient temperatures at or below 81 degrees Fahrenheit for a minimum of ninety-six hours; the Administrator did not know whether there was a local ordinance or other restriction that prohibited the facility from storing additional fuel; and in the event of a power loss, the facility would be cooled by the use of portable air conditioners that Respondent had not yet purchased. 16. On or about September 26, 2018, at 12:08 p.m., the Agency’s representative further interviewed Respondent’s Administrator who stated the following: a. Respondent had not yet acquired services or a process necessary to maintain and test its generators; Respondent did not have a plan to obtain additional fuel in the event of an emergency; Respondent did not have carbon monoxide alarms; Respondent had not yet developed policies and procedures for the alternate power source and fuel; e. Respondent did not notify its residents or their legal representatives in writing when the emergency plan was submitted for review and approval; and f. the Administrator planned to contract with a gas company to provide the services to maintain and test the generator and to deliver additional fuel onsite in the event of an emergency. 17. The above reflects Respondent’s failure to maintain a copy of its Emergency Power Plan (“EPP”) at the facility, failed to acquire services to maintain and test its alternate power sources, failed to have a process necessary to maintain and test its alternate power source, failed to develop written policies and procedures to ensure that the facility would effectively and immediately operate and maintain the alternate power source and any fuel required for the operation of the alternate power source, failed to have a plan to obtain additional fuel in an emergency, failed to acquire carbon monoxide alarms, and failed to notify the residents or their legal representatives in writing within five days of submitting its EPP to the local emergency management agency for review and approval. 18. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than a Class | violation, and cited Respondent with a Class II deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(b), Florida Statutes (2018). 19. 20. 21. COUNT II The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. Section 435.12(2)(b-d), Florida Statutes, provides: (b) Until such time as the fingerprints are enrolled in the national retained print arrest notification program at the Federal Bureau of Investigation, an employee with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency. (c) An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. (d) An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic fingerprint submission to the Department of Law Enforcement. The registration must include the employee’s full first name, middle initial, and last name; social security number; date of birth; mailing address; sex; and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number. On or about September 26, 2018, the Agency conducted a complaint investigation survey (#2018009556) of Respondent’s facility. 22. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to maintain the employment status of all employees in the background screening clearinghouse within ten business days of employment status changes, the same being contrary to the mandates of law. 23, On or about September 26, 2018, at 9:42 a.m., the Agency’s representative reviewed Respondent’s background clearinghouse employee roster and noted that Respondent’s Administrator and Staff A were not listed on the roster. 10 24, The Agency’s representative reviewed Respondent’s personnel records and noted that Staff A had a hire date of August 1, 2018 and the Administrator had been in her role at the facility since December 27, 2016. 25. On or about September 26, 2018, at 11:45 a.m., the Agency’s representative interviewed Respondent’s Administrator who confirmed the above findings by the Agency’s representative. 26. The above reflect Respondent’s failure to maintain the employment status of all employees within the background screening clearinghouse as evidenced by Respondent’s failure to update the employment roster to include Respondent’s Administrator and Staff A. 27. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider other than class I, class II, class III, or class IV violations and cited Respondent for an unclassified violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(e), Florida Statutes (2018). COUNT II 28. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. Section 408.809(1) Florida Statutes, provides: (1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest. 30. 31, 32, (e) Any person, as required by authorizing statutes, secking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients, or contracting with a licensee or provider to work 20 hours a week or more who will have access to client funds, personal property, or living areas. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. Section 435.02(2), Florida Statutes, provides: “Employee” means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers. Section 435.06(2), Florida Statutes, provides: (2)(a) An employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the agency as provided under s. 435.Q7. (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s. 435.07. (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. On or about September 26, 2018, the Agency conducted a complaint survey (#2018009556) of Respondent’s facility. 33. | Based upon interviews and the review of records by the Agency’s representative, Respondent failed to conduct a level 2 background screening on individuals with unlimited access to client living areas, the same being contrary to the mandates of law. 34. On or about September 26, 2018, at 9:15 am., the Agency’s representative toured Respondent’s facility and noted the following: a. there were two people in the facility, a man who identified himself as the Administrator’s husband and a woman who said she was a visitor that cleaned the facility (housekeeper); b. both of the non-resident individuals that the Agency’s representative witnessed in the facility had unrestricted access to all of the residents’ rooms; and c. other than the residents of the facility and the two non-residents identified above, there were no other individuals present in the facility. 35. The Agency’s representative interviewed the Administrator’s husband and questioned the husband about who was in charge of the facility, but the Administrator’s husband did not answer the question and stated only that the Administrator went to the store and would be returning soon. 36. On or about September 26, 2018, at 9:30 a.m., the Agency’s representative interviewed the housekeeper who stated the housekeeper arrived at the facility the night of September 25, 2018, and that she did not work at the facility. 37. | The Agency’s representative requested that the housekeeper provide her date of birth and social security number so that a review of the Agency’s background screening website could be checked for an eligible screening, but the housekeeper declined to provide her social security number. 13 38. The Agency’s representative reviewed the Agency’s background screening website by using only the housekeeper’s date of birth and her identified name, but the search revealed no matches. 39, On or about September 26, 2018, at 9:32 a.m., Respondent’s Administrator arrived at the facility, at which time the Administrator’s husband and the housekeeper left the facility. 40. On or about September 26, 2018, at 9:39 a.m., the Agency’s representative interviewed Respondent’s Administrator who stated the following: a. the housekeeper was a friend who helped with sweeping the facility; b. the housekeeper did not have an eligible background screening; c. other than the housekeeper’s name, the Administrator was unable to provide any additional identifiers for the housekeeper, such as date of birth or social security number; and d. Caregiver A was at the facility at 7:00 a.m. but had to leave for an emergency, so the Administrator’s husband was left in charge of the residents on the morning of the survey. 41. On or about September 26, 2018, at 9:44 a.m., the Agency’s representative interviewed Respondent’s Administrator who stated the following: a. neither the Administrator’s husband nor the housekeeper held a_ valid cardiopulmonary resuscitation or first aid card; and Db. the Administrator’s husband did not have an eligible background screening. 42. | The Agency’s representative reviewed the Agency’s background screening website using the identifying information that the Administrator provided for the Administrator’s husband and could locate no background screening results. 14 43. On or about September 26, 2018, at 11:20 am., when Caregiver A arrived at Respondent's facility, the Agency’s representative interviewed Caregiver A who stated the following: a. Caregiver A was scheduled to work at the facility on September 26, 2018 from 7:00 a.m. to 7:00 p.m., but she had an emergency and was not able to come in until 11:20 a.m.; and b. Caregiver A was not at the facility on the morning of the current survey. 44. The Agency’s representative reviewed Respondent’s staffing schdule and noted that neither the Respondent’s Administrator’s husband nor the housekeeper were listed on the facility’s staffing schedule. 45. | The above reflect Respondent’s failure to conduct a level 2 background screening on individuals with unlimited access to client living areas as evidenced by Respondent’s failure to obtain level 2 background screenings for the housekeeper and for Administrator’s husband, who was in charge of the residents during the survey. 46. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider other than class I, class I], class Ill, or class IV violations and cited Respondent for an unclassified violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(e), Florida Statutes (2018). COUNT IV 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. 49. Rule 58A-5.0191(5) of the Florida Administrative Code provides: (5) FIRST AID AND CARDIOPULMONARY RESUSCITATION (CPR). A. staff member who has completed courses in First Aid and CPR and holds a currently valid card documenting completion of such courses must be in the facility at all times. (a) Documentation that the staff member possess current CPR certification that requires the student to demonstrate, in person, that he or she is able to perform CPR and which is issued by an instructor or training provider that is approved to provide CPR training by the American Red Cross, the American Heart Association, the National Safety Council, or an organization whose training is accredited by the Commission on Accreditation for Pre-Hospital Continuing Education satisfies this requirement. (b) A nurse shall be considered as having met the training requirement for First Aid. An emergency medical technician or paramedic currently certified under chapter 401, Part Ill, F.S., shall be considered as having met the training requirements for both First Aid and C.P.R. On or about September 26, 2018, the Agency conducted a complaint investigation survey (#2018009556) of Respondent’s facility. 50. Based upon interviews by the Agency’s representative, Respondent failed to maintain staff that held a currently valid card documenting completion of First Aid and Cardiopulmonary Resuscitation (“CPR”) in the facility at all times, the same being contrary to the mandates of law. S51. On or about September 26, 2018, at 9:15 a.m., the Agency’s representative toured Respondent’s facility and noted the following: a. there were two people in the facility, a man who identified himself as the Administrator’s husband and a woman who said she was a visitor that cleaned the facility (housekeeper); b. both of the non-resident individuals that the Agency’s representative witnessed in the facility had unrestricted access to all of the residents’ rooms; and c. other than the residents of the facility and the two non-residents identified above, there were no other individuals present in the facility. 16 52. The Agency’s representative interviewed the Administrator’s husband and questioned the husband about who was in charge of the facility, but the Administrator’s husband did not answer the question and stated only that the Administrator went to the store and would be returning soon. 53. On or about September 26, 2018, at 9:30 a.m., the Agency’s representative interviewed the housekeeper who stated the housekeeper arrived at the facility the night of September 25, 2018 and that she did not work at the facility. 54. | The Agency’s representative requested that the housekeeper provide her date of birth and social security number so that a review of the Agency’s background screening website could be checked for an eligible screening, but the housekeeper declined to provide her social security number. 55. On or about September 26, 2018, at 9:32 a.m., Respondent’s Administrator arrived at the facility, at which time the Administrator’s husband and the housekeeper left the facility. 56. On or about September 26, 2018, at 9:39 a.m., the Agency’s representative interviewed Respondent’s Administrator who stated the following: a. the housekeeper was a friend who helped with sweeping the facility; b. the housekeeper did not have an eligible background screening; c. other than the housekeeper’s name, the Administrator was unable to provide any additional identifiers for the housekeeper, such as date of birth or social security number; and d. Caregiver A was at the facility at 7:00 a.m. but had to leave for an emergency, so the Administrator’s husband was left in charge of the residents on the morning of the survey. 57. On or about September 26, 2018, at 9:44 a.m., the Agency’s representative interviewed Respondent’s Administrator who stated the following: a. neither the Administrator's husband nor the housekeeper held a_ valid cardiopulmonary resuscitation or first aid card; and b. the Administrator’s husband did not have an eligible background screening. 58. The above reflects Respondent’s failure to maintain staff that held a currently valid card documenting completion of First Aid and CPR in the facility at all times. 59. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threatens the physical or emotional health, safety, or security of clients, other than class J or class II violations and cited Respondent for a Class HI violation. 60. Florida law requires that cited deficient practice be corrected within thirty (30) days. See § 408.811(4), Fla. Stat., (2018). 61. | On or about December 27, 2018, the Agency conducted a revisit to the September 2018 survey of Respondent’s facility. 62. : Based upon interviews by the Agency’s representative, Respondent failed to maintain staff that held a currently valid card documenting completion of a First Aid course in the facility at all times, the same being contrary to the mandates of law. 63. | The Agency’s representative reviewed Respondent’s personnel file for Staff A and noted the following: a. Staff A was hired by Respondent on January 8, 2018; b. while Respondent had documentation demonstrating that Staff A completed a CPR course on February 15, 2018, Staff A had no documented evidence of having completed a First Aid course 64. The above reflects Respondent’s failure to maintain staff that held a currently valid card documenting completion of a First Aid course in the facility at all times. 65. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threatens the physical or emotional health, safety, or security of clients, other than class I or class II violations and cited Respondent for a Class III violation. 66. | The same constitutes an uncorrected Class III deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2018). COUNT V 67. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 68. Rule 58A-5.026(2) of the Florida Administrative Code provides: (2) EMERGENCY PLAN APPROVAL. The plan must be submitted for review and approval to the local emergency management agency. (a) If the local emergency management agency requires revisions to the emergency management plan, such revisions must be made and the plan resubmitted to the local office within 30 days of receiving notification that the plan must be revised. (b) A new facility as described in Rule 58A-5.023, F.A.C., and facilities whose ownership has been transferred, must submit an emergency management plan within 30 days after obtaining a license. (c) The facility must review its emergency management plan on an annual basis. Any substantive changes must be submitted to the local emergency agency for review and approval. 19 1. Changes in the name, address, telephone number, or position of staff listed in the plan are not considered substantive revisions for the purposes of this rule. 2. Changes in the identification of specific staff must be submitted to the local emergency management agency annually as a signed and dated addendum that is not subject to review and approval. (d) The local emergency management agency is the final administrative authority for emergency management plans prepared by assisted living facilities. (e) Any plan approved by the local emergency management agency is considered to have met all the criteria and conditions established in this rule. 69. On or about September 26, 2018, the Agency conducted a complaint investigation survey (#2018009556) of Respondent’s facility. 70. Based upon interviews by the Agency’s representative, Respondent failed to obtain and maintain an approved Comprehensive Emergency Management Plan (“CEMP”), the same being contrary to the mandates of law. 71. On or about September 26, 2018, at 9:55 a.m. and 10:01 a.m., the Agency’s representative interviewed Respondent’s Administrator and requested to review Respondent’s most recent approval letter for its CEMP, and the Administrator responded that Respondent’s most recent approval letter for its CEMP was at the home of the consultant who was updating Respondent’s CEMP. 2. The Agency’s representative gave the Respondent's Administrator an opportunity to provide Respondent’s CEMP to the Agency’s representative for review during the survey, but Respondent’s Administrator was unable to provide a copy of the approval letter for Respondent’s CEMP by the end of the survey. 73. The above reflects Respondent’s failure to obtain and maintain an approved CEMP. 74. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or 20 potentially threatens the physical or emotional health, safety, or security of clients, other than class I or class II violations and cited Respondent for a Class II violation. 75. Florida law requires that cited deficient practice be corrected within thirty (30) days. See § 408.811(4), Fla. Stat., (2018). 76. On or about December 27, 2018, the Agency conducted a revisit to the September 2018 survey of Respondent’s facility. 77, Based upon interviews and the review of records by the Agency’s representative, Respondent failed to obtain and maintain an approved CEMP, the same being contrary to the mandates of law. 78. On or about December 27, 2018, at 12:30 p.m., Respondent’s Administrator provided its CEMP aproval letter to the Agency’s representative who noted that the letter was dated September 28, 2017 and valid through September 28, 2018 (expired). 79. On further review of Respondent’s CEMP submission to the local emergency management agency, the Agency’s representative noted that Respondent did not submit its proposed CEMP to the local emergency management agency sixty days before the CEMP expiration date as required, but rather Respondent submitted its proposed CEMP to the local emergency management agency on December 12, 2018, after the date of expiration of Respondent’s CEMP. 80. On or about December 27, 2018, at 12:45 p.m., the Agency’s representative interviewed Respondent’s Administrator who confirmed the Agency representative’s findings above and stated that the Administrator hired a consultant to handle the facility’s emergency management plan submissions to the local emergency management agency. 81. The above reflect Respondent’s failure to obtain and maintain an approved CEMP. 21 82. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threatens the physical or emotional health, safety, or security of clients, other than class I or class II violations and cited Respondent for a Class III violation. 83. | The same constitutes an uncorrected Class II] deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2018). COUNT VI 84. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count I as if fully set forth herein. 85. On or about December 27, 2018, the Agency conducted a revisit to the September 2018 survey of Respondent’s facility. 86. Based upon interviews by the Agency’s representative, Respondent failed to maintain a copy of its EPP at the facility and failed to maintain documentation demonstrating that Respondent notified the residents and the residents’ representatives when Respondent’s EPP was submitted to the local emergency management agency for review and approval, the same being contrary to the mandates of law. 87. On or about December 27, 2018, at 8:00 a.m., the Agency’s representative reviewed Respondent’s previous EPP approval and noted that Respondent received approval of its EPP on September 28, 2017 and implemented the EPP on September 20, 2017. 22 88. On or about December 27, 2018, at 12:30 p.m., the Agency’s representative requested to review the required documents concerning Respondent’s current EPP but Respondent’s Administrator could not provide any current documentation. 89. On or about December 27, 2018, at 12:45 p.m., the Agency’s representative interviewed Respondent’s Administrator who stated the following: a. the Administrator hired a consultant to handle all of Respondent’s emergency management plans; b. the consultant was responsible for sending out the letters to the residents and the residents’ representatives about the EPP being submitted for review and approval; c. the consultant was responsible for developing Respondent’s written policies and procedures; and d. to the best of the Administrator’s knowledge, the consultant did submit Respondent’s EPP to the local emergency management agency for review and approval on December 12, 2018. 90. The above reflects Respondent’s failure to maintain a copy of its EPP at the facility and its failure to maintain documentation demonstrating that Respondent notified the residents and the residents’ representatives when Respondent’s EPP was submitted to the local emergency management agency for review and approval. 91. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threatens the physical or emotional health, safety, or security of clients, other than class I or class II violations and cited Respondent for a Class III violation. 92. The same constitutes an uncorrected Class III deficiency. 23 WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2018). COUNT VI 6. The Agency re-alleges and incorporates paragraphs (1) through (5) and Counts IV and V as if fully set forth herein. 7. Pursuant to section 429.19(7), Florida Statutes (2018), “[iJn addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of a 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 to verify the correction of the violations.” 8. Respondent is therefore subject to a survey fee of up to five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2018). WHEREFORE, the Agency intends to impose a survey fee of three hundred eighty-eight dollars and seventy-five cents ($388.75) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(7), Florida Statutes (2018). COUNT VIII 93. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 94. Section 435.12(2)(b-d), Florida Statutes, provides: (b) Until such time as the fingerprints are enrolled in the national retained print arrest notification program at the Federal Bureau of Investigation, an employee with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency. 24 (c) An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. (d) An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic fingerprint submission to the Department of Law Enforcement. The registration must include the employee’s full first name, middle initial, and last name; social security number; date of birth; mailing address; sex; and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number. 95. On or about January 29, 2019, the Agency conducted a re-licensure survey of Respondent’s facility. 96. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to maintain the employment status of all employees in the background screening clearinghouse within ten business days of employment status changes, the same being contrary to the mandates of law. 97. On or about January 29, 2019, at 11:30 a.m., the Agency’s representative reviewed Respondent’s employee roster and noted the following: a. Staff B, a current employee, was not listed on the roster; and b. Staff D, an employee that ended their employment with Respondent in December 2018, was still listed on Respondent’s employee roster. 98. The above reflect Respondent’s failure to maintain the employment status of all employees within the background screening clearinghouse as evidenced by Respondent's failure to update the employment roster for Staff B and Staff D. 99. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider other than class I, class II, class II, or class IV violations and cited Respondent for an unclassified violation. 25 WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(e), Florida Statutes (2018). COUNT IX 100. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 101. Section 408.809(1) Florida Statutes, provides: (1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients, or contracting with a licensee or provider to work 20 hours a week ot more who will have accéss to client funds, personal property, or living areas. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. 102. Section 435.02(2), Florida Statutes, provides: “Employee” means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers. 103. Section 435.06(2), Florida Statutes, provides: (2)(a) An employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening 26 process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the agency as provided under s. 435.07. (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s. 435.07. (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. 104. On or about January 29, 2019, the Agency conducted a re-licensure survey of Respondent’s facility. 105. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to conduct a level 2 background screening on individuals with unlimited access to client living areas, the same being contrary to the mandates of law. 106. On or about January 29, 2019, at 9:45 a.m., the Agency’s representative began the survey and observed a gentleman opening the door to the facility who identified himself as the Administrator’s husband and stated that he was alone with the facility’s five residents. 107. On or about January 29, 2019, at 9:50 a.m., Respondent’s Administrator arrived at the facility, at which time the Agency’s repersentative interviewed Respondent’s Administrator who stated the following: a. the Administrator’s husband did not work at the facility; and b. the Administrator left the hospice staff at the facility with the residents. 27 108. After the Agency representative’s interview with Respondent’s Administrator, the Agency’s representative informed the Administrator that Respondent’s residents could not be left in the facility for the hospice staff to be responsible for the residents. 109. On or about January 29, 2019, at 10:15 a.m., the Agency’s representative interviewed Respondent’s Administrator who stated that the Administrator did not obtain a level 2 background screening for the Administrator’s husband. 110. On or about January 29, 2019, at 11:30 a.m., the Agency’s representative reviewed the Agency’s background screening website and noted that there was a background screening result for the name of the Administrator’s husband. 111. The above reflect Respondent’s failure to conduct a level 2 background screening on individuals with unlimited access to client living areas as evidenced by Respondent’s failure to obtain level 2 background screenings for the Administrator’s husband. 112. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider other than class I, class II, class II, or class IV violations and cited Respondent for an unclassified violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(e), Florida Statutes (2018). Respectfully submits hip el Sey gtt cheno 2020. Michael S. Roscoe, Esquire Fla. Bar. No. 0125286 Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1944 (office) Facsimile 727.552.1440 Michael.Roscoe@ahca.myflorida.com 28 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. 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, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2510 0001 4448 3173 on ia ae, 2020, to Bobsilyn Duncan, Administrator and Registered Agent for Bobsilyn Duacan d/b/a Prestige Place ALF, 256 Barbarossa Road, Palm Bay, Florida 32907 Cote Michael S. Roscoe, Esquire Copy furnished to: Theresa DeCanio Field Office Manager Agency for Health Care Administration 29 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Bobsilyn Duncan d/b/a AHCA No. 2019002618 Prestige Place ALF 2019003909 2019004301 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 #7 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 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 30 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. 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 to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: 31 SENDER: COMPLETA 6 SECTION COMPLETE THIS SECTIOpmi@N DELIVERY @ Complete items 1, 2, and 3. ™ Print your name and address on the reverse O Agent so that we can return the card to you. . o Addressee | Attach this card to the back of the mailpiece, . eet by (Printed Name) C. Date of Delivery or on the front if space permits. : nd. 1. Article Addressed to: D._Js delivery address different from item 12 [I Yes Bobsilyn Duncan “AL YES, enter delivery address below: = [] No Administrator and Registered Agent for Prestige Place ALF 256 Barbarossa Road Palm Bay, Florida 32907 100 00 9590 9402 5660 9308 2853 61 PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt + USPS TRACKING # Ildpeds fl | aa valid, First-Class Mail Postage & Fees Paid USPS il | lh HH pm Un tes Postigiservee 2 f—] * Sender: Please print your name, address, and ZIP+4® in this box® Agency for Health Care Legal Office of the General Counsel 525 Mirror Lake Drive North Ste. #330 St. Petersburg, Florida 33701 M.R. 26902618 RECE! GENERAL CO MAR EXHIBIT 2

Docket for Case No: 20-003420