‘FILED | September 3, 2020 STATE OF FLORIDA . ; : , - AGENCY FOR PERSONS WITH DISABILITIES Agency Clerk | Agency for Persons with Disabilities AGENCY FOR PERSONS | WITH DISABILITIES, Petitioner, Vv. . . License Number: 7G462A _ BRIAR OAKS GROUP HOME, OWNED AND OPERATED BY CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS, INC., . Respondent. / ADMINISTRATIVE COMPLAINT The AGENCY FOR PERSONS WITH DISABILITIES, (“Agency”), issues this Administrative Complaint against Briar Oaks Group Home, owned and operated by Crystal. Lake Supportive Environments, Inc. (or “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 following address: 5008 Briar Oak Circle, ~ Orlando, Florida 32808. 3. Crystal Lake Supportive Environments, Inc. is a registered Florida not for profit 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 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: 11. 12. 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; or (b) The Department of Children and Families has verified that the licensee i is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. . COUNT I The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about Apri 19, 2019, at approximately 3: 00 am, K. M, a vulnerable adult resident of Respondent’s Briar Oaks Group Home, eloped from the home. K.M. has an extensive, documented history of elopement and other dangerous behaviors and requires an increased level of staffing to ensure continuous supervision. K.M. wears an ankle monitor and requires delayed-egress locks on the exterior doors of the home to prevent elopement. On or about J anuary 6, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later located by police and returned to the home. On or about August 23, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M was found by police several hours later and Baker Acted. On or about November 21, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home K.M. was found by police approximately one hour later and returned to the home. On or about January 16, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was subsequently located by police and was Baker Acted. On or about February 19, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was not located by police until late in the evening on or about February 19, 2017 and required medical attention for a rash and injury to his foot. On or about May 2, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later arrested and charged with burglary and assault. 13. 14. 15. 16. 17. 18, 19, 20. 21, On or about June 5, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later located by police and returned to the home. On or about October 1, 2018, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was located by police and Baker Acted. At the time of K.M.’s April 19, 2019, elopement, one staff member was on duty at the Briar Oaks Group Home. The sole staff member on duty was asleep at the time that K.M. eloped, and the delayed-egress locks on the front door did not function or sound an alarm as they should have. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, and line of sight supervision by staff while inside the house and awake. On or about April 19, 2019, the Department of Children and Families (“DCF”) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about April 28, 2019, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for al! of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable tules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. It was foreseeable by the Respondent that K.M. would attempt to elope from the facility again, based on his lengthy history of elopement from the facility. Respondent, as the owner and operator of the Briar Oaks Group Home, has custody and control over the facility employees and residents. Despite K.M.’s history of elopement, Respondent failed to ensure adequate staffing and supervision in the 22. 23. 24, 25, 26. 27. 28. facility and failed to ensure delayed-egress door locks and alarms were functioning properly. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT II The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about June 24, 2019, at approximately 2:30 am, K.M., a vulnerable adult resident of Respondent’s Briar Oaks Group Home, eloped from the home. K.M. has an extensive, documented history of elopement and other dangerous behaviors and requires an increased level of staffing to ensure continuous supervision. K.M. wears an ankle monitor and requires delayed-egress locks on the exterior doors of the home to prevent elopement. At the time of K.M.’s elopement on or about June 24, 2019, only one staff member was on duty at the Briar Oaks Group Home. The sole staff member was asleep at the time that K.M. eloped, and the delayed-egress locks on the front door did not function or sound an alarm as they should have. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, and line of sight supervision by staff while inside the house and awake. . On or about June 25, 2019, the Department of Children and Families (“DCF”) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about August 8, 2019, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee. — After K.M.’s previous elopement on April 19, 2019, the Respondent indicated that the door alarm had malfunctioned, and would be repaired. K.M. wears an ankle monitor to track him when he elopes, he requires delayed egress doors and alarms, and awake overnight staff to prevent elopement. Elopement is identified as a target behavior for reduction in K.M.’s behavior services plan, which was developed by the Respondent. In this instance in June 24, 2019, Respondent failed to ensure 29, 30. 31. 32. 33. 34. 35. functioning door alarms and locks and failed to ensure awake staff were present to provide the level of supervision required by K.M. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for all of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable tules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT III The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about March 13, 2020, at approximately 4:30 am, K.M., a vulnerable adult resident of Respondent’s Briar Oaks Group Home, went into the kitchen, turned on the stove, and proceeded to set paper towels and copier paper on fire. He dropped a light paper towel on the floor of the kitchen and put burning papers in the bedroom of another resident, on top of the resident’s shoes. K.M. has an extensive, documented history of dangerous behaviors including setting a van with passengers in it on fire. He requires a higher level of staffing to ensure continuous supervision and prevent these dangerous behaviors. At the time of the March 13, 2020, incident, there was only one staff member on duty at the Briar Oaks Group Home. The sole staff member was asleep at the time that K.M. started burning items in the kitchen. Also, this particular staff member 36. 37. 38. 39. 40. 41. 42. 43. did not routinely work at the Briar Oaks Group Home, was not aware of the specific behaviors of the residents and was not trained on their supervision requirements. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, with a staff positioned immediately next to his bedroom door, and line of sight supervision by staff while inside the house and awake. On or about March 15, 2020, the Department of Children and Families (“DCF”) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about April 30, 2020, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee Andrew Carter. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for all of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable rules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or.abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT IV The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about September 26, 2019, the Agency issued a notice of non-compliance letter to the Respondent in response to numerous Class I violations that occurred in 45. 46. 47. 48. 49. nine group homes operated by the Respondent, including the Briar Oaks Group Home, and required the Respondent to submit a corrective action plan (“CAP”) within 10 days. Respondent submitted a corrective action plan in response to the Agency’s letter. The CAP required specific elements, including documentation of employee retraining on the resident-specific behavior and safety plans and their individual supervision needs and procedures. Respondent was required to ensure staff were trained on those items, prior to being assigned to supervise residents. For homes serving residents with safety plans or a documented history of elopement, such as Briar Oaks Group Home, the Respondent was required to ensure two awake staff are present during the overnight shift. On or about May 19, 2020, the Agency requested documentation of the number of staff present during the fire-setting incident at Briar Oaks Group Home on March 13, 2020. The Agency also requested documentation that employee Andrew Carter was trained on the behavior plans and supervision needs for the Briar Oaks residents, and whether a review of the recorded video in the home was conducted by the Respondent. On or about May 20, 2020, Respondent acknowledged that during the fire-setting incident at Briar Oaks on March 13, 2020, there was only one staff on duty instead of two as required by the Respondent’s CAP. Respondent also acknowledged that staff Andrew Carter was not trained on the behavior plans and supervision needs for the Briar Oaks residents, and that their review of the recorded video in the home showed that staff Andrew Carter was asleep at the time of the incident. Pursuant to Rule 65G-2.0041(2), Florida Administrative Code, the Agency shall consider the following factors when determining the sanctions for a violation, to include the gravity of the violation; the lack of remedial action being taken by the: licensee to correct the violation; whether the violation is a repeat violation; if the licensee willfully committed the violation; and the licensee’s cooperation with the Agency. Fla. Admin. Code R. 65G-2.0041. Despite the corrective action plan submitted by the Respondent, a Class I violation of verified findings of abuse, neglect, or exploitation of the same vulnerable adult resident occurred again on or about March 13, 2020 at the Respondent’s Briar Oaks Group Home. Respondent is aware of the staffing and supervision required for resident K.M., and after the first two incidents with K.M. in 2019, submitted a corrective action plan to ensure adequate staffing and supervision were provided. As evidenced by the incident on March 13, 2020, involving the same resident, Respondent has failed to remediate the violation and failed to implement their corrective action plan, thereby failing to protect the health and safety of K.M. and other residents of the group home. Upon notice and opportunity to cure the deficiencies identified in the CAP, Respondent failed to ensure that adequate staff were present in the home to prevent 50. 51. 32. residents from engaging in life-threatening behaviors. Respondent failed to properly train staff to provide the required level of supervision and behavioral interventions to facility residents. The facility shall adhere to and protect resident rights and freedoms in accordance with the Bill of Rights of Persons with Developmental Disabilities, as provided in section 393.13, F.S. Violations of section 393.13(3)(a), F.S. relating to humane care, abuse, sexual abuse, neglect, or exploitation and all violations of section: 393.13(3)(g), F.S., shall constitute a Class I violation. Fla. Admin. Code R. 65G- 2.009(1)(d). The Agency may revoke a license if the licensee has failed to comply with the rules applicable to the licensee. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated section 393.0673, Florida Statutes, by violating Rule 65G-2.009(1)(d), Florida Administrative Code, by violating their corrective action plan after notice and opportunity to cure, and by failing to adhere to and protect residents rights and freedoms in accordance with the Bill of Rights of Persons with Developmental Disabilities, as provided in section 393.13, Florida Statutes. ; Based on the foregoing and pursuant to section 393.0673, Florida Statutes, the Agency requests that a Final Order be entered that revokes the Respondent’s license or places any less penalty against Respondent’s license as proscribed by law. Dated September 3, 2020 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: Craig Cook Crystal Lake Supportive Environments, Inc. 2710 Staten Road, Suite A Orlando, Florida 32804 Jeannette Estes Regional Operations Manager APD Central Region agency for persons with disabilities State of Florida 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. 2. 4. 5. 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; 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; , 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); A statement of when you received notice of the administrative complaint; and 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@apdeares.org . : (850) 922-4556 (phone) Mediation under s.120.573, Florida Statutes, is (850) 410-0665 (fax) not available for this proceeding. Rev. OGC May 19, 2017 http:/apdeares.org FILED September 3, 2020 STATE OF FLORIDA AGENCY FOR PERSONS WITH DISABILITIES Agency Clerk Agency for Persons with Disabilities AGENCY FOR PERSONS WITH DISABILITIES, Petitioner, v. License Number: 7G462A BRIAR OAKS GROUP HOME, OWNED AND OPERATED BY CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS, INC., Respondent. / ADMINISTRATIVE COMPLAINT The AGENCY FOR PERSONS WITH DISABILITIES, (“Agency”), issues this Administrative Complaint against Briar Oaks Group Home, owned and operated by Crystal Lake Supportive Environments, Inc. (or “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 following address: 5008 Briar Oak Circle, Orlando, Florida 32808. 3. Crystal Lake Supportive Environments, Inc. is a registered Florida not for profit 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 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; or (b) The Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT I The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about April 19, 2019, at approximately 3:00 am, K.M., a vulnerable adult resident of Respondent’s Briar Oaks Group Home, eloped from the home. K.M. has an extensive, documented history of elopement and other dangerous behaviors and requires an increased level of staffing to ensure continuous supervision. K.M. wears an ankle monitor and requires delayed-egress locks on the exterior doors of the home to prevent elopement. On or about January 6, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later located by police and returned to the home. On or about August 23, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M was found by police several hours later and Baker Acted. On or about November 21, 2016, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home K.M. was found by police approximately one hour later and returned to the home. On or about January 16, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was subsequently located by police and was Baker Acted. On or about February 19, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was not located by police until late in the evening on or about February 19, 2017 and required medical attention for a rash and injury to his foot. On or about May 2, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later arrested and charged with burglary and assault. 13. 14. 15. 18. 19. 20. 21. On or about June 5, 2017, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was later located by police and returned to the home. On or about October 1, 2018, Respondent submitted an incident report to the Agency stating resident K.M. eloped from the Briar Oaks Group Home. K.M. was located by police and Baker Acted. At the time of K.M.’s April 19, 2019, elopement, one staff member was on duty at the Briar Oaks Group Home. The sole staff member on duty was asleep at the time that K.M. eloped, and the delayed-egress locks on the front door did not function or sound an alarm as they should have. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, and line of sight supervision by staff while inside the house and awake. On or about April 19, 2019, the Department of Children and Families (“DCF’’) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about April 28, 2019, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for all of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable tules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. It was foreseeable by the Respondent that K.M. would attempt to elope from the facility again, based on his lengthy history of elopement from the facility. Respondent, as the owner and operator of the Briar Oaks Group Home, has custody and control over the facility employees and residents. Despite K.M.’s history of elopement, Respondent failed to ensure adequate staffing and supervision in the 22. 23. 24, 25. 26. 27. 28. facility and failed to ensure delayed-egress door locks and alarms were functioning properly. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT II The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about June 24, 2019, at approximately 2:30 am, K.M., a vulnerable adult resident of Respondent’s Briar Oaks Group Home, eloped from the home. K.M. has an extensive, documented history of elopement and other dangerous behaviors and requires an increased level of staffing to ensure continuous supervision. K.M. wears an ankle monitor and requires delayed-egress locks on the exterior doors of the home to prevent elopement. At the time of K.M.’s elopement on or about June 24, 2019, only one staff member was on duty at the Briar Oaks Group Home. The sole staff member was asleep at the time that K.M. eloped, and the delayed-egress locks on the front door did not function or sound an alarm as they should have. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, and line of sight supervision by staff while inside the house and awake. On or about June 25, 2019, the Department of Children and Families (“DCF”) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about August 8, 2019, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee. After K.M.’s previous elopement on April 19, 2019, the Respondent indicated that the door alarm had malfunctioned, and would be repaired. K.M. wears an ankle monitor to track him when he elopes, he requires delayed egress doors and alarms, and awake overnight staff to prevent elopement. Elopement is identified as a target behavior for reduction in K.M.’s behavior services plan, which was developed by the Respondent. In this instance in June 24, 2019, Respondent failed to ensure 29. 30. 31. 32. 33, 34, 35. functioning door alarms and locks and failed to ensure awake staff were present to provide the level of supervision required by K.M. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for all of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable tules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT III The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about March 13, 2020, at approximately 4:30 am, K.M., a vulnerable adult resident of Respondent’s Briar Oaks Group Home, went into the kitchen, turned on the stove, and proceeded to set paper towels and copier paper on fire. He dropped a light paper towel on the floor of the kitchen and put burning papers in the bedroom of another resident, on top of the resident’s shoes. K.M. has an extensive, documented history of dangerous behaviors including setting a van with passengers in it on fire. He requires a higher level of staffing to ensure continuous supervision and prevent these dangerous behaviors. At the time of the March 13, 2020, incident, there was only one staff member on duty at the Briar Oaks Group Home. The sole staff member was asleep at the time that K.M. started burning items in the kitchen. Also, this particular staff member 36. 37. 38. 39, 40. 41. 42. 43. did not routinely work at the Briar Oaks Group Home, was not aware of the specific behaviors of the residents and was not trained on their supervision requirements. K.M. receives behavior analysis services to address his behavior problems. His behavior service plan requires 15-minute checks by group home staff when he is in his bedroom asleep, with a staff positioned immediately next to his bedroom door, and line of sight supervision by staff while inside the house and awake. On or about March 15, 2020, the Department of Children and Families (“DCF’’) commenced an investigation involving allegations of abuse, neglect or exploitation of a vulnerable adult. On or about April 30, 2020, DCF closed their investigation with verified findings of abuse, neglect or exploitation of a vulnerable adult against the Respondent’s employee Andrew Carter. Each facility must provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained. Direct service providers must be given specific information and strategies to provide such an environment for all of residents of the facility. A violation of this subsection shall constitute a Class I violation. Fla. Admin. Code R. 65G-2.009(6)(a). The Agency may revoke a license or impose an administrative fine if the licensee has failed to comply with the applicable requirements of this chapter or applicable tules. § 393.0673, Fla. Stat. The Agency may revoke a license or impose an administrative fine if the Department of Children and Families has verified that the licensee is responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated: Rule 65G-2.009(6)(a), Florida Administrative Code, by failing to provide the level of supervision necessary to ensure that residents are protected from harm and that a safe and healthy living environment is created and maintained and by failing to provide direct service providers with specific information and strategies to provide such an environment for all residents of the facility; and section 393.0673, Florida Statutes, by being found responsible for the abuse, neglect, or abandonment of a child or the abuse, neglect, or exploitation of a vulnerable adult. COUNT IV The Agency re-alleges and incorporates paragraphs one through four as if fully set forth herein. On or about September 26, 2019, the Agency issued a notice of non-compliance letter to the Respondent in response to numerous Class I violations that occurred in 4A. 45. 46. 47. 48. 49. nine group homes operated by the Respondent, including the Briar Oaks Group Home, and required the Respondent to submit a corrective action plan (“CAP”) within 10 days. Respondent submitted a corrective action plan in response to the Agency’s letter. The CAP required specific elements, including documentation of employee retraining on the resident-specific behavior and safety plans and their individual supervision needs and procedures. Respondent was required to ensure staff were trained on those items, prior to being assigned to supervise residents. For homes serving residents with safety plans or a documented history of elopement, such as Briar Oaks Group Home, the Respondent was required to ensure two awake staff are present during the overnight shift. On or about May 19, 2020, the Agency requested documentation of the number of staff present during the fire-setting incident at Briar Oaks Group Home on March 13, 2020. The Agency also requested documentation that employee Andrew Carter was trained on the behavior plans and supervision needs for the Briar Oaks residents, and whether a review of the recorded video in the home was conducted by the Respondent. On or about May 20, 2020, Respondent acknowledged that during the fire-setting incident at Briar Oaks on March 13, 2020, there was only one staff on duty instead of two as required by the Respondent’s CAP. Respondent also acknowledged that staff Andrew Carter was not trained on the behavior plans and supervision needs for the Briar Oaks residents, and that their review of the recorded video in the home showed that staff Andrew Carter was asleep at the time of the incident. Pursuant to Rule 65G-2.0041(2), Florida Administrative Code, the Agency shall consider the following factors when determining the sanctions for a violation, to include the gravity of the violation; the lack of remedial action being taken by the licensee to correct the violation; whether the violation is a repeat violation; if the licensee willfully committed the violation; and the licensee’s cooperation with the Agency. Fla. Admin. Code R. 65G-2.0041. Despite the corrective action plan submitted by the Respondent, a Class I violation of verified findings of abuse, neglect, or exploitation of the same vulnerable adult resident occurred again on or about March 13, 2020 at the Respondent’s Briar Oaks Group Home. Respondent is aware of the staffing and supervision required for resident K.M., and after the first two incidents with K.M. in 2019, submitted a corrective action plan to ensure adequate staffing and supervision were provided. As evidenced by the incident on March 13, 2020, involving the same resident, Respondent has failed to remediate the violation and failed to implement their corrective action plan, thereby failing to protect the health and safety of K.M. and other residents of the group home. Upon notice and opportunity to cure the deficiencies identified in the CAP, Respondent failed to ensure that adequate staff were present in the home to prevent 50. 51. 52. residents from engaging in life-threatening behaviors. Respondent failed to properly train staff to provide the required level of supervision and behavioral interventions to facility residents. The facility shall adhere to and protect resident rights and freedoms in accordance with the Bill of Rights of Persons with Developmental Disabilities, as provided in section 393.13, F.S. Violations of section 393.13(3)(a), F.S. relating to humane care, abuse, sexual abuse, neglect, or exploitation and all violations of section 393.13(3)(g), F.S., shall constitute a Class I violation. Fla. Admin. Code R. 65G- 2.009(1)(d). The Agency may revoke a license if the licensee has failed to comply with the rules applicable to the licensee. § 393.0673, Fla. Stat. Based on the foregoing, Respondent violated section 393.0673, Florida Statutes, by violating Rule 65G-2.009(1)(d), Florida Administrative Code, by violating their corrective action plan after notice and opportunity to cure, and by failing to adhere to and protect residents rights and freedoms in accordance with the Bill of Rights of Persons with Developmental Disabilities, as provided in section 393.13, Florida Statutes. Based on the foregoing and pursuant to section 393.0673, Florida Statutes, the Agency requests that a Final Order be entered that revokes the Respondent’s license or places any less penalty against Respondent’s license as proscribed by law. Dated September 3, 2020 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: Craig Cook Crystal Lake Supportive Environments, Inc. 2710 Staten Road, Suite A Orlando, Florida 32804 Jeannette Estes Regional Operations Manager APD Central Region ago agency for persons with disabilities State of Florida 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) 922-4556 (phone) Mediation under s.120.573, Florida Statutes, is (850) 410-0665 (fax) not available for this proceeding. Rev. OGC May 19, 2017 http://apdcares.org

Docket for Case No: 20-004472FL