18-006677 Agency For Health Care Administration vs. Blue Angel Enterprises, Inc., D/B/A Blue Angel Residences Status: Closed Recommended Order on Friday, July 5, 2019.

Summary: AHCA proved that Respondent engaged in unlicensed activity and committed background screening violations, sufficient to revoke its license and levy fines, but did not prove that Respondent failed to timely correct a medication storage deficiency.

ST ATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Petitioner,

vs. Case No. 18 - 6677

BLUE ANGEL ENTERPRISES, INC.,

d/b/a BLUE ANGEL RESIDENCES,

Respondent.

_______________________________/

R ECOMMENDED ORDER

The final hearing in this matter was conducted before

Administrative Law Judge Andrew D. Manko of the Division of

Administrative Hearings (ÐDOAHÑ), pursuant to sections 120.569

and 120.57(1), Florida Statutes (2018), 1/ on May 7 and 8, 201 9,

by video teleconference between sites in Tallahassee and

St. Petersburg , Florida , and on May 24, 2019, in St. Petersburg .

APPEARANCES

For Petitioner: Nicola Brown, Esquire

Gisela Iglesias, Esquire

Agency for Health Ca re Administration

Suite 330H

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

For Respondent: Jeffrey Scott Howell, Esquire

Rickey L. Strong, Esquire

Jeffrey S. Howell, P.A.

2898 - 6 Mahan Drive

Tallahassee, Florida 32308

STATEMENT OF THE ISSUE

Whether Blue Angel Enterprises, Inc., d/b/a Blue Angel

Residences (ÐBlue AngelÑ) , committed the statutory or rule

violations alleged in the Amended Administrative Complaint and,

if so, what penalty is authorized for such violations.

PRELIMINARY STATEMENT

On May 2, 2018, the Agency for Health Care Administration

(AHCA) issued a six - count a dministrative c omplaint against Blue

Angel, seeking to impose fines and revoke its assisted living

facility license for engaging in unlicensed activity, failing to

complete background screening and maintain an updated background

screening roster, failing to ensure medication was properly

secured, and opera ting beyond its licensed capacity. On May 25,

2018, Blue Angel disputed the allegations and requested a

hearing pursuant to section 120.57(1).

On December 18, 2018, AHCA referred the administrative

complaint to DOAH to conduct a formal administrative hear ing

under section 120.57. The final hearing was initially set for

February 18 and 19, 2019, but was continued upon agreement of

the parties and rescheduled for May 7 and 8, 2019.

Before the hearing, AHCA moved to determine no justiciable

issues of materia l fact on two of the six counts. The

undersigned denied the motion without prejudice to re newing it

at the hearing after the evidence had been presented.

The final hearing began on May 7, 2019. That morning, a

proposed intervenor ÏÏ whose facility was the subject of a number

of allegations in the administrative complaint but was neither

named as a respondent nor served with the complaint ÏÏ filed

motions to intervene and for continuance. Before any evidence

was presented, the undersigned heard arguments and, on agreement

of the parties and the proposed intervenor, AHCA filed an

a mended a dministrative c omplaint that removed all allegations

concerning the proposed intervenorÓs facility and the proposed

intervenor withdrew its motions.

On May 8, 2019, AHCA beg an its case - in - chief and presented

the testimony of five witnesses: Unidad Bonoan, Laura Manville,

Steven Brodsky, Rod Jean - Gilles, and Serita Evans. PetitionerÓs

Exhibits 1 through 30, 33 through 41, 44, 47, and 49 through 51

were admitted without objec tion. The undersigned took official

recognition of PetitionerÓs Exhibit 44.

On May 24, 2019, Blue Angel began its case - in - chief and

presented the testimony of three witnesses: Maria Aussendorf,

Saili Hernandez, and Edelma Perez Garcia. RespondentÓs Ex hibits

3, 7, 15, and 18 were admitted without objection.

On May 24, 2018, AHCA presented one witness in its rebuttal

case, Sharon Lawrence.

A three - volume T ranscript of the final hearing was filed on

June 10, 20 19 . The part ies timely filed their Propose d

Recommended Order s (ÐPRO s Ñ), which were duly considered in

preparing this Recommended Order.

To maintain confidentiality of the residents and staff at

issue, the parties have referred to residents by number and to

staff by letter throughout these proceed ings. The undersigned

utilizes the same system in this R ecommended O rder. 2/

FINDING S OF FACT

1. AHCA is the state agency charged with licensing of

assisted living facilities (ALFs) in Florida , pursuant to the

authority in chapters 408, part II, and 429, part I, Florida

Statutes, and Florida Administrative Code Chapter 58A - 5. AHCA

is authorized to evaluate ALFs to determine their compliance

with statutes and rules regulating the ir licensure and

operation.

2. Blue Angel, located in Tampa, Florida, has bee n a

licensed ALF (#12211) since 2012 with an operating capacity of

six beds. It is licensed to provide limited mental health

services, participates in long - term care, and is a licensed

adult daycare facility. Ms. Aussendorf owns the property,

serves as B lue AngelÓs chief financial officer (ÐCFOÑ), and also

assists with clinical care because she is a nurse. Armando

Vazquez, Ms. AussendorfÓs brother, serves as Blue AngelÓs

president and administrator.

3. An ALF is a structure (whether a building, part o f a

building, or multiple buildings) that provides housing, meals,

and one or more personal services to residents for at least

24 hours. These personal services typically include assistance

with activities of daily living , such as bathing, dressing,

ambu lating, and feeding, among others. It also can include

assistance with self - administration of medication, whereby the

facility stores the medication in a locked cabinet, retrieves

it, observes the resident taking it, and then documents that it

was taken.

4. When an ALF applies for a license, it typically submits

floor plans of the facility along with reports from local fire,

zoning, and health agencies to ensure the structure meets

regulatory and safety standards. AHCA reviews the application

materials a nd conducts an inspection of the structure(s) to be

licensed. If approved, the license is issued for the particular

structure(s) inspected.

5. The property on which Blue Angel is located has two

structures. The main building, located in the front of th e

property, has been licensed as an ALF since 2012. The back

structure, located behind the main building, has never been

licensed as an ALF. Ms. Aussendorf renovated the back structure

in 2013 , and lived in it for several months before ÐrentingÑ it

to fo ur residents. Blue AngelÓs characterization of these

residents as independent, as opposed to assisted living, is one

of the primary issues in this case.

6. AHCA conducts inspections, called surveys, of licensed

ALFs to determine their compliance with go verning statutes and

rules. AHCA has a right of entry to conduct surveys at licensed

ALFs at any time.

7. ALFs are subject to bi - annual surveys, during which

surveyors tour the facility, review resident and staff records,

and observe compliance with co re standards, medication storage,

and direct care to residents. Surveyors interview residents,

family members, and staff. Complaint surveys are conducted when

AHCA receives a complaint from the public, another agency, or

anonymously; those surveys are fo cused to the area of concern.

Revisit surveys are conducted to ensure that any deficiencies

cited in a prior survey have been corrected.

8. Surveyors also have authority to investigate unlicensed

facilities if they suspect that unlawful activity is occu rring,

though entering an unlicensed building without the ownerÓs

permission could be a violation of the ownerÓs rights.

9. If an ALF is not in compliance with the law, AHCA

classifies the deficiencies based on the level of threat to the

safety and welf are of the residents. They are categorized as

Class I, II, III, IV, or unclassified deficiencies. Class III

deficiencies are the most common and involve an indirect threat

to the health or well - being of the residents. AHCA typically

gives the ALF 30 day s to correct a Class III deficiency before

seeking to impose a fine or penalty. An unclassified deficiency

is one that does not meet the other classifications and often

requires a fine or penalty to be assessed. A finding of

unlicensed activity is treate d as an unclassified deficiency,

which often results in action being taken against the license.

10. On January 9, 2018, AHCAÓs surveyors, Mr. Brodsky and

Mr. Jean - Gilles, conducted a complaint survey at Blue Angel for

allegedly operating beyond its six - be d capacity. The complaint

was not specific to the unlicensed back structure so the focus

upon arrival was on the licensed main building.

11. Upon arrival at 6:00 p.m. , the surveyors spoke to

Staff A about the complaint, told her to contact the owner, a nd

requested the admission/discharge log. Although Ms. Aussendorf

was not present initially, she arrived about 30 minutes later.

12. Things were chaotic when the surveyors arrived due to

a shift change and residents being moved around the facility,

inc luding out the back door and into the back structure. As a

result, Mr. Brodsky inspected the main building, while Mr. Jean -

Gilles went out back to inspect the unlicensed back structure.

13. In the main building, Mr. Brodsky interviewed several

residents , including Resident 1, who said he lived in the main

building. Resident 1Ós file contained a document showing an

admission date of December 2016, which indicated he had dementia

and needed assistance with bathing, dressing, and ambulation,

among others. He also was apparently admitted back into Blue

Angel from the hospital in July 2017. Ms. Aussendorf maintained

that Resident 1 was only there as an adult day care patient and

went home every day, though his daughter told Mr. Brodsky on the

phone that eve ning that he lived there. The surveyors believed

that seven residents (including Resident 1) were living in the

main building, one more than Blue AngelÓs license allowed.

14. Meanwhile, Mr. Jean - Gilles went out back and spoke to

Staff C. She permitted h im to enter the back structure. He

observed a common area with a bunkbed and kitchenette, one

bedroom with two beds, and another bedroom with one bed.

15. An unlocked cabinet in the kitchenette contained

medication belonging to residents who lived in th e main building

and some who no longer lived in the facility. The majority of

the medication was expired.

16. Mr. Jean - Gilles observed Residents 14, 15, and 16 in

the back structure, interviewed them, spoke to Resident 13

outside the back structure, an d contacted family members. 3/

Those interviews revealed the following:

• Resident 13 lives in the back structure and moved there

from an ALF in Nebraska. Blue Angel provides her with

meals, cleans her room, and brings a groomer for her dog.

• Resident 14 lives in the back structure and shares a room

with another resident . Blue Angel assist s her with

bathing in the main building, change s her clothes, and

provides her meals. She also uses a walker because she

is not stable due to ParkinsonÓs Disease .

• R esident 15 live s in the back structure and has for about

five weeks after being discharged from the hospital . She

s hare s the bunkbed with Staff C . Blue Angel provide s her

with meals , assist s her with medication, and assisted her

with bathing initially . Her son confirmed that she has

dementia and needs assistance with everything.

• Resident 16 lives in the back structure and share s a room

with Resident 14 . Blue Angel assist s her with her

medication. A nurse c omes to check her blood pressure

and arrange her medicine in organizers.

17. Mr. Jean - Gilles interviewed Staff C during the survey

and she informed him of the following:

• She live s in the back structure , supervise s the residents

at night , and helps them as needed . She assist s all of

them with their medication and confirmed they ate meals

in the main building. She also sometimes fills in during

day shifts .

• As to Resident 13, she bathes on her own in the back

structure because she is in better shape than the others.

But staff assists and wat ches her take her medication.

• As to Resident 14, Staff C or daytime staff assists her

with bathing in the main building and changing her

clothes because she is unstable and needs help.

• As to Resident 16, Staff C or daytime staff assists her

with bathing in the main building and changing clothes.

18. Mr. Jean - Gilles also interviewed Staff D during the

survey and she informed him of the following:

• She has worked there for three years and, though the

residents in the back structure are independent, they do

need supervision and assistance.

• As to Resident 13, she is independent and staff does not

need to help her with anything.

• As to Resident 14, she walks by herself but also

occasionally uses a walker. Staff D supervises her when

she bathes so she does n ot fall. Staff makes sure she

takes her medication during snacks and meals, but she

does it in her room. Resident 14 also has been

incontinent and staff helps to clean her.

• As to Resident 15, she initially bathed in the main

building, but now does so i n the back structure. She is

assisted with her medication by Ms. Aussendorf.

• As to Resident 16, she is independent. Staff does not

watch her or give her medication. She showers in the

back structure.

19. Mr. Jean - Gilles also reviewed Blue AngelÓs files

pertaining to Residents 13, 14, 15, and 16, which were kept in

the main building even though they lived in the back structure.

20. All four residents executed residential leases with

Blue Angel, signed by Ms. Aussendorf, whereby Blue Angel agreed

to cl ean their rooms and assist them with laundry and meals.

The leases prohibited the residents from having guests without

prior written consent, required them to sign in/out before

leaving the premises, and mandated that they be on the premises

by 9 p.m. Re sident 16 also signed an ALF contract with Blue

Angel after she moved in, which indicated that her rent would

start at $700 but increase to $1,500 once she was enrolled in a

long - term care program.

21. Residents 13, 14, and 16 each had ALF resident health

assessment forms (AHCA Form 1823). These forms were completed

by healthcare providers and confirmed that the residents needed

assistance with personal services that would be met at an ALF.

Each form listed Blue Angel as the licensed ALF, Ms. Aussendorf

as the facility contact, and detailed the following information:

• Resident 13 (signed by Ms. Aussendorf on January 28,

2016) - she had schizophrenia - paranoid type, needed

assistance with self - administration of medication, and

needed daily oversight as to wh ereabouts and well - being ,

but was independent as to activities of daily life .

• R esident 14 (unsigned but dated October 23, 2017 ) - she

was unsteady, used a walker, and had a tremor, needed

supervision with bathing, meals, handling personal and

financial affairs, assistance with self - administration of

medication, and daily oversight as to her well - being ,

whereabouts, and reminders for important tasks.

• Resident 16 (unsigned, undated) - she needed supervision

with bathing, transferring, preparing meals, s hopping,

handling personal affairs, and ambulati ng because she is

unsteady , and needed daily oversight as to her well -

being , whereabouts, and reminders for important tasks.

22. Blue AngelÓs files contained medical logs and forms

for Residents 13, 14, 15, and 16, which is not typical for

independent residents. The files contained the following:

• Resident 13 Î monthly logs tracking her medications and

the time of day taken from November 2017 through January

2018; monthly logs tracking her weight from Novembe r 2013

through April 2015; monthly progress notes from March

through May 2015 indicating that Blue Angel checked her

vitals, though noting she was very independent;

certificate of Medicaid necessity signed by her medical

provider, indicating that she neede d assistance with

self - administration of medication and health support,

such as observing her whereabouts and well - being,

reminders of important tasks, and recording and reporting

significant changes in appearance and behavior ; community

living support pla n, naming Blue Angel as the ALF and

noting she needed assistance with medication management .

• Resident 14 Î monthly log s tracking her weight from

December 2015 through July 2016 .

• Resident 15 Î undated and unsigned observation log

i ndicat ing that Blue Ange l checked her vitals, though

noting she was independent.

• Resident 16 Î log tracking her medications and the time

of day taken for Jan uary 2018; copies of prescriptions

noting Blue Angel as the facility or listing its address.

23. The su rveyors reviewed t he AHCA b ackground screening

c learinghouse a gency website to ensure all staff screenings were

current. They discovered that Staff CÓs level II background

screening had expired just a few days before the survey.

24. The surveyors walked around with Ms. Aussendorf to

identify the issues they found. While in the back structure,

they showed Ms. Aussendorf the unlocked medication cabinet and

she acknowledged they were expired. They observed her removing

medicine from the packaging and giving it to Resident 15 because

she could not read the labels. Ms. Aussendorf admitted to

assisting Resident 15 with her medication, but maintained that

the residents in the back structure were independent.

25. Although Staff D and Ms. Aussendorf gave conflicting

testimony as to the services provided, the undersigned finds the

testimony of Mr. Jean - Gilles and Mr. Brodsky to be credible,

particular ly viewed in the context of the documents in Blue

AngelÓs files, the statements made by staff and residents , and

the observations made by the surveyors during the survey.

26. Before leaving that evening, the surveyors informed

Ms. Aussendorf of the following deficiencies: overcapacity

based on Resident 1 in the main building and the four residents

in the back structure, the backg round screening issue, and the

medication storage issue in the back structure. They did not

inform her, show her their notes, or discuss an allegation of

unlicensed activity. Thus, at that point, Blue Angel had no

notice of that allegation.

27. The we ek following the survey, Ms. Aussendorf called

Ms. Manville, AHCAÓs supervisor for the local field office.

According to Ms. Aussendorf, Ms. Manville said the residents

could not live in the back structure and that, though an exact

deadline could not be gi ven, she should be fine if she moved

them before the revisit survey .

28. Based on that call, Ms. Aussendorf began to find other

places for the four residents. Although there is conflicting

evidence as to the date on which the last resident moved out,

there is no dispute that Residents 13, 14, and 16 moved to other

ALFs and Resident 15 moved in with her daughter.

29. On January 22, 2018, AHCA issued its Notice of

Unlicensed Activity. Based on the weight of the credible

evidence, this was the first da te that AHCA notified Blue Angel

that the activities in the back structure constituted unlicensed

activity, as opposed to mere overcapacity.

30. In a letter dated January 25, 2018, AHCA reported its

findings and enclosed a summary statement of deficienc ies citing

the following four deficiencies: Tag 0055 - medication storage

and disposal, r ule 58A - 5.0185(6) (Class III); Tag Z815 Î

background screening, sections 408.809, 435.02(2), and 435.06

(unclassified); Tag Z827 Î unlicensed activity (Residents 13,

14, 15, and 16 living in the back structure), section 408.812;

and Tag Z828 Î administrative fines and violations (overcapacity

as to Resident 1 living in main building), section 408.813(3).

The letter required all deficiencies to be corrected within 30

d ays of the date of the letter and mandated that a corrective

action plan be submitted by February 4, 2018.

31. Blue Angel timely submitted its corrective action plan

and indicated that all deficiencies were corrected as follows:

• Unlicensed Activity - Al l residents had been moved out of

the back structure.

• Background Screening Î Staff C had been scheduled for a

background screening appointment as of the date of the

survey and, on January 10, 2018, completed the

rescreening and was in compliance.

• Overcap acity Î Resident 1 was an adult daycare patient

and his family had informed AHCA about their

misunderstanding.

• Medications Î All employees received additional training,

medication was now locked in secure cabinets, and all

expired medication was sent to th e pharmacy and

destroyed.

32. AHCAÓs surveyors, Mr. Jean - Gilles, Ms. Evans, and

Ms. Hardie, returned to Blue Angel to conduct a revisit survey

on February 26, 201 8 . Ms. Aussendorf was out of the country,

but the staff granted access to the surveyors. The surveyors

spoke to staff, inquired about the number of residents currently

living in the facility, and inspected the back structure.

33. As to the main building, the surveyors observed an

unlocked medication cabinet that included medication for six

residents present in the main building and two residents,

including Resident 1, who were not present.

34. As to the back structure, Staff C confirmed she lived

there, but no belongings of the four residents remained. The

surveyors spoke to staff, revie wed records , and called or

visited the residents, their family members, and the new ALFs to

confirm when the residents moved out of the back structure.

35. The parties dispute when the last resident moved out

of the back structure . Blue Angel maintai ns that it was

January 23, 2018 , whereas AHCA maintain s that it was

February 13, 2018. The evidence on this issue ÏÏ testimony from

AHCAÓs witnesses and its own exhibits ÏÏ is conflicting. 4/

However, the undersigned finds that the weight of the credible

evid ence, including in particular the testimony of Ms. Evans,

established that Resident 16 moved out on January 16, 2018,

Residents 13 and 14 moved out on January 18, 2018, and Resident

15 moved out on January 23, 2018.

36. The revisit survey also revealed that Residents 13,

14, and 16 received long - term care services, including some type

of supervision and assistance, and were eligible to receive

Medicaid managed care services. Long - term care services are not

offered to residents in independent facilities because such

services indicate a need for supervision or assistance with

daily activities of life. Ms. Aussendorf helped some of the

residents with their applications for long - term care plans.

37. As required by the long - term care plans, Residents 13,

14 , and 16 had assigned case manager s who conduct ed in - person

visits. Ms. Lawrence, Resident 13Ós case manager, confirmed

that she is unable to take care of her own needs, including food

preparation, medication, and transportation. Ms. Lawrence

visited Res ident 13 on Wednesdays to ensure that her bills were

paid and her medications were stocked and taken correctly, and

to assist with anything else she needed.

38. The revisit survey lastly revealed that Blue Angel

failed to maintain its background scre ening clearinghouse

employee roster. The surveyors reviewed the employee records

and found that five employees had been omitted from the roster.

39. Based on the complaint and revisit surveys, AHCA

pursued disciplinary action against Blue Angel. On May 2, 2018,

AHCA filed an administrative complaint seeking to impose

administrative fines and to revoke Blue AngelÓs license.

40. On May 8, 2019, AHCA served an amended administrative

complaint seeking the same relief based on the following six

counts: ( I ) administrative fine of $35,000 ($1,000 per day) for

unlicensed activity in the bac k structure from January 9, 2018 ,

through February 13, 2018, pursuant to section 408.812;

( II ) license revocation for the unlicensed activity in the back

structure, pursuan t to sections 429.14(1)(j) and 408.815(1)(c);

( III ) administrative fine of $500 for failing to maintain an

updated background screening clearinghouse employee roster,

pursuant to sections 429.19(2)(c) and 408.815(1)(c);

( IV ) administrative fine of $500 for failing to secure

medication in a locked storage room or cabinet, pursuant to

section 429.19(2)(c); ( V ) administrative fine of $500 for

failing to conduct a level II background screening for an

employee, pursuant to sections 429.19(2)(c) and 408.813(3)(b) ;

and ( VI ) administrative fine of $500 for overcapacity, pursuant

to section 408.813(3). 5 /

41. Blue Angel admitted the allegations of Counts III , V ,

and VI and conceded to the $500 fines imposed in each.

FINDINGS OF ULTIMATE FACT

42. It is well settled u nder Florida law that determining

whether alleged misconduct violates a statute or rule is a

question of ultimate fact to be decided by the trier - of - fact

based on the weight of the evidence . Holmes v. Turlington ,

480 So. 2d 150, 153 (Fla. 1985); McKinney v. Castor , 667 So. 2d

387, 389 (Fla. 1st DCA 1995); Langston v. Jamerson , 653 So. 2d

489, 491 (Fla. 1st DCA 1995). Thus, determining whether the

alleged misconduct violates the law is a factual, not legal,

inquiry.

43. AHCA has the burden to prove its a llegations against

Blue Angel by clear and convincing evidence. Dep Ó t of Banking &

Fin. v. Osborne Stern & Co. , 670 So. 2d 932, 934 (Fla. 1996) ;

Avalon Ó s Assisted Living, LLC v. Ag . for Health Care Admin . ,

80 So. 3d 347, 348 - 49 (Fla. 1 st DCA 2011 ) (citin g Ferris v.

Turlington , 510 So. 2d 292 , 294 - 95 (Fla. 1987) ) . As the Florida

Supreme Court has stated:

Clear and convincing evidence requires that

the evidence must be found to be credible;

the facts to which the witnesses testify

must be distinctly rememb ered; the testimony

must be precise and explicit and the

witnesses must be lacking in confusion as to

the facts in issue. The evidence must be of

such weight that it produces in the mind of

the trier of fact a firm belief or

conviction, without hesitancy, as to the

truth of the allegations sought to be

established.

In re Henson , 913 So. 2d 579, 590 (Fla. 2005) (quoting Slomowitz

v. Walker , 429 So. 2d 797, 800 (Fla. 4th DCA 1983)).

44. Based on the findings of fact above, AHCA established

by clear and co nvincing evidence that Blue Angel engaged in

unlicensed activity in the back structure. §§ 408.812(2) &

429.04, Fla. Stat. The weight of the credible eviden ce proved

that Blue Angel provided housing, meals, and multiple personal

services for more than 24 hours in the back structure to

Residents 13, 14, 15, and 16, none of whom were relatives of

Blue AngelÓs owners. £ 429.02(5), Fla. Stat. Specifically, it

supervised and/or assisted residents with bathing (Residents 14,

15, and 16), ambulating (Residents 14 and 15), dressing

(Residents 14 and 16), washing clothes (all four residents), and

self - administration of medication, including storing, bringing

it to the resident, verbally reading the label, and maintaining

records tracking same (all four residents) . See Avalon Ó s

Assisted Living , 80 So. 3d at 348 - 49 (holding that Ðpersonal

servicesÑ as defined in section 429.02, includes Ðwashing

clothes and feeding, bathing, grooming, and administering

medications to its residentsÑ).

45. Based on the findings of fact above and the weight of

the credible evidence, AHCA failed to establish by clear and

convincing evidence that it put Blue Angel on notice of the

unlicensed activity allegation on January 9, 201 8 , the date of

the complaint survey, nor that Blue Angel did not cease such

operations until February 13, 2018. Instead, the undersigned

finds that the weight of the credible evidence established that

AHCA put Blue Angel on notice of the unlicensed activity

violation on January 22, 2018, when it issued its noti ce of

unlicensed activity, and that Blue Angel ceased such activity by

January 23, 2018, the date the last resident moved out.

46. Based on the findings of fact above and the weight of

the credible evidence, AHCA established by clear and convincing

evid ence that Blue Angel knowingly and unlawfully operated the

back structure as an ALF without a license in violation of

sections 429.14(1)(j), 408.812(2), and 408.815(1)(c). Blue

Angel used its licensed structure to serve the residents meals,

bath e some of them, and maintain their files. The Form 1823s

listed Blue Angel as the receiving ALF and Ms. Aussendorf as the

contact, and detailed the personal services these four residents

needed . Ms. Aussendorf, Blue AngelÓs CFO and a controlling

interest, owned th e property, acted on Blue AngelÓs behalf in

handling issues with AHCA , and had clear knowledge of the types

of services ALFs provide. The leases with the residents listed

Blue Angel as the landlord and were signed by Ms. Aussendorf.

And, the leases detai led b road personal services provided by

Blue Angel and imposed movement restrictions , which would not

apply in an independent facility.

47. Based on the findings of fact above and the weight of

the credible evidence, AHCA established by clear and co nvincing

evidence that Blue Angel violated r ule 58A - 5.0185(6) by failing

to keep the centrally - stored medication cabinet in the back

structure locked and properly dispose of the expired medications

found therein. However, AHCA did not establish by clear a nd

convincing evidence that Blue Angel failed to timely correct

that Class III deficiency ( e.g. , keeping medication in an

unlocked cabinet in the unlicensed back structure). The

evidence was undisputed that Blue Angel had properly removed all

of the medic ation from the cabinet in the back structure and,

thus , a fine cannot be imposed. § 408.813(2)(c), Fla. Stat.

CONCLUSIONS OF LAW

48. DOAH has jurisdiction over the parties and the subject

matter of this cause. §§ 120.569 & 120.57(1), Fla. Stat.

Cou nt I Î $35,000 Fine for Unlicensed Activity 6 /

49. AHCA seeks to impose an administrative fine against

Blue Angel for unlicensed activity. § 408.812(4), Fla. Stat.

50. Section 429.04(1) requires ALFs to be licensed.

Although the statute contains several exemptions, none of them

are applicable here. § 429.04(2), Fla. Stat.

51. An ALF is defined as:

[A] ny building or buildings , section or

distinct part of a building, private home,

boarding home, home for the aged, or other

residential facility, rega rdless of whether

operated for profit, which through its

ownership or management provides housing,

meals, and one or more personal services for

a period exceeding 24 hours to one or more

adults who are not relatives of the owner or

administrator .

§ 429. 02(5), Fla. Stat. (emphases added).

52. Ð P ersonal servicesÑ are defined as:

direct physical assistance with or

supervision of the activities of daily

living, the self - administration of

medication, or other similar services which

the department may define by rule. The term

may not be construed to mean the provision

of medical, nursing, dental, or mental

health services.

§ 429.02(17), Fla. Stat.

53. ÐActivities of daily livingÑ are defined as Ð functions

and tasks for self - care, including ambulation, bath ing,

dressing, eating, grooming, and toileting, and other similar

tasks. Ñ £ 429.02(1), Fla. Stat.

54. Ð Supervision Ñ is defined as Ð reminding residents to

engage in activities of daily living and the self - administration

of medication, and, when necessar y, observing or providing

verbal cuing to residents while they perform these activities. Ñ

§ 429.02(24), Fla. Stat.

55. As authorized by section 429.02(17), AHCA has further

defined assistance with activities of daily li ving to include

Ðindividual assistan ceÑ with any of the following:

(a) Ambulation - Providing physical support

to enable the resident to move about within

or outside the facility. Physical support

includes supporting or holding the

resident's hand, elbow, or arm; holding on

to a support b elt worn by the resident to

assist in providing stability or direction

while the resident ambulates; or pushing the

resident's wheelchair. The term does not

include assistance with transfer.

(b) Bathing - Assembling towels, soaps, or

other necessary sup plies; helping the

resident in and out of the bathtub or

shower; turning the water on and off;

adjusting water temperatures; washing and

drying portions of the body that are

difficult for the resident to reach; or

being available while the resident is

bath ing.

(c) Dressing - Helping residents to choose,

put on, and remove clothing.

(d) Eating - Helping residents with or by

cutting food, pouring beverages, or feeding

residents who are unable to feed themselves.

(e) Grooming - Helping residents with

sha ving, oral care, care of the hair, or

nail care.

(f) Toileting - Assisting the resident to

the bathroom, helping the resident to

undress, positioning the resident on the

commode, and helping the resident with

related personal hygiene including

assistance with changing an adult brief and

assistance with the routine emptying of a

catheter or ostomy bag.

Fla. Admin. Code R. 58A - 5.0131 .

56. ÐAssistance with self - administration of medicationÑ is

defined by statute to include:

( a) Taking the medication, in i ts

previously dispensed, properly labeled

container, including an insulin syringe that

is prefilled with the proper dosage by a

pharmacist and an insulin pen that is

prefilled by the manufacturer, from where it

is stored, and bringing it to the resident.

(b) In the presence of the resident,

reading the label, opening the container,

removing a prescribed amount of medication

from the container, and closing the

container.

(c) Placing an oral dosage in the

residentÓs hand or placing the dosage in

another c ontainer and helping the resident

by lifting the container to his or her

mouth.

* * *

(e) Returning the medication container to

proper storage.

(f) Keeping a record of when a resident

receives assistance with self - administration

under this sec tion.

* * *

(l) Assisting with measuring vital signs.

£ 429.256(3), Fla. Stat. Additionally, Ðassistance with self -

administration of medication includes, in the presence of the

resident, reading the medication label aloud and verbally

prompting a resident to take medications as prescribed.Ñ Fla.

Admin. Code R. 58A - 5.0185(3)(b).

57. Section 408.812(2) provides that Ð[t]he operation or

maintenance of an unlicensed provider or the performance of any

services that require licensure without proper licensure is a

violation of this part and authorizing statutes.Ñ

58. Based on the findings of fact and ultimate fact above,

AHCA proved by clear and convincing evidence that Blue Angel

engaged in unlicensed activity in the back structure by

providing hous ing, meals, and Ðpersonal servicesÑ for more than

24 hours to Residents 13, 14, 15, and 16, in violation of

sections 429.04(1) and 408.812(2).

59. AHCA seeks to impose an administrative fine of

$35,000 ÏÏ $1,000 for each day that Blue Angel failed to ceas e

operating the unlicensed facility after agency notification.

§ 408.812(3), (4), Fla. Stat. AHCA contends that Blue Angel was

put on notice of the unlicensed activity on January 9, 2018, the

date of the complaint survey, and did not cease operations unt il

February 13, 2018, the date AHCA contends Resident 13 moved out

of Blue Angel.

60. However, the clock for correcting the cited deficiency

does not run from verbal communications of agency staff, but

instead from the providerÓs receipt of written notice of the

deficiency. See § 408.811 (4), Fla. Stat. (requiring deficiency

to Ð be corrected within 30 calendar days after the provider is

notified of inspection results Ñ); Fla. Admin. Code R. 59A -

35.120(1)(a) (ÐD eficiencies must be corrected within 30 days of

the date the Agency sends the de ficiency notice to the

provider... .Ñ ); Fla. Admin. Code R. 58A - 5.033(2) (a) (requiring

agency to Ð issue a statement of deficiency Ñ for violations

observed during inspections with a timeframe for correction).

AHCAÓs argumen t has been previously rejected. See Pinehurst

Convalescent Ctr. v. Ag . for Health Care Admin. , 814 So. 2d 452,

453 (Fla. 4th DCA 2001) (Ð The notion that a nursing home could

suffer a substantial fine or lose its license based solely on

verbal communicatio n makes about as much sense as the notion

that police officers could issue verbal traffic citations. Ñ).

61. Moreover, even if verbal notice was sufficient, the

surveyors conceded that they never informed Blue Angel of an

unlicensed activity violation at the complaint survey and

instead solely discussed an allegation of overcapacity, which is

a distinct violation with differing penalties. And, to boot,

the evidence was undisputed that AHCAÓs staff never gave Blue

Angel a timeframe for correction.

62. B ased on the findings of fact and ultimate fact above

and the weight of the credible evidence, AHCA established by

clear and convincing evidence that Blue Angel was put on notice

of the allegation of unlicensed activity on January 22, 2018,

when it issued i ts notice of unlicensed activity, and that

violation was corrected one day later, on January 23, 2018, when

the last resident moved out of the back structure.

63. For the foregoing reasons, the undersigned concludes

that a fine of $1,000 is appropriate u nder section 408.812. 7 /

Count II Î License Revocation for Unlicensed Activity

64. AHCA also seeks to revoke Blue AngelÓs license for

engaging in unlicensed activity, pursuant to sections

429.14(1)(j) and 408.815(1)(c).

65. Section 429.14(1)(j) authori zes AHCA to revoke Blue

AngelÓs license for Ð[k] nowingly operating any unlicensed

facility or providing without a license any service that must be

licensed under this chapter or chapter 400. Ñ

66. Based on the findings of fact and ultimate fact above,

AHC A established by clear and convincing evidence that Blue

Angel engaged in unlicensed activity in the back structure and

did so knowingly, in violation of sections 429.04(1),

429.14(1)(j), and 408.812(2).

67. The undersigned rejects Blue AngelÓs argument that

AHCAÓs failure to notify it on prior surveys that the back

structure had to be licensed undermines the knowing nature of

its conduct. AHCA had no reason to inspect the back structure

because Blue Angel never applied for it to be licensed. And,

Blue AngelÓs knowledge of its unlawful activity cannot be

ignored simply because it evaded being caught for several years.

The conduct of Blue AngelÓs CFO upon being caught confirmed the

knowing nature of the violation, as she tried to convince AHCA

that the residents were independent.

68. Section 408.815(1)(c) also authorizes AHCA to revoke

Blue AngelÓs license if a Ðcontrolling interestÑ commits Ð[a]

violation of this part, authorizing statutes, or applicable

rules.Ñ A Ðcontrolling interestÑ includes the Ð licensee Ñ and

Ð[a] person or entity that serves as an officer of, is on the

board of directors of, or has a 5 - percent or greater ownership

interest in the applicant or licensee ,Ñ so long as the person is

not a voluntary board member. § 408.803(7)(a) & ( b), Fla. Stat.

69. Based on the findings of fact and ultimate fact above,

AHCA established by clear and convincing evidence that Blue

Angel along with its CFO, Ms. Aussendorf, unlawfully operated

the unlicensed facility in the back structure in violation of

sections 408.812(2) & (3) and 408.815(1)(c) .

70. For the foregoing reasons, the undersigned concludes

that revocation of Blue AngelÓs license is appropriate.

Count III Î $500 Fine for Failing to Maintain Updated Background

Screening Clearinghouse Ros ter

71. AHCA seeks to impose an administrative fine for Blue

AngelÓs failure to maintain an updated background screening

clearinghouse employee roster for five of six employees, as

required by section 435.12, Florida Statutes. AHCA seeks to

impose a $50 0 fine for this violation pursuant to sections

429.19(2)(e) and 408.815(1)(c).

72. Blue Angel admitted to the allegations in Count III

and to the $500 administrative fine imposed therein.

Count IV - $500 Fine for Failing to Secure Medication

73. AHCA s eeks to impose a $500 administrative fine for

Blue AngelÓs failure to correct a class III deficiency within 30

days, as required by 429.19(2)(c) .

74. The law requires ALFs that centrally store medications

for residents keep them Ðin a locked cabinet; lo cked cart; or

other locked storage receptacle, room, or area at all timesÑ and

ensure abandoned or expired medications are Ðdisposed of within

30 days of being determined abandoned or expired.Ñ Fla. Admin.

Code R. 58A - 5.0185(6)(c)1. & (f).

75. Section 408.813(2)(c) defines Class III violations as:

those conditions or occurrences related to

the operation and maintenance of a provider

or to the care of clients which the agency

determines indirectly or potentially

threaten the physical or emotional healt h,

safety, or security of clients, other than

class I or class II violations. The agency

shall impose an administrative fine as

provided in this section for a cited class

III violation. A citation for a class III

violation must specify the time within wh ich

the violation is required to be corrected.

If a class III violation is corrected within

the time specified, a fine may not be

imposed.

76. After the complaint survey, AHCA cited Blue Angel for

failing to ensure that medications were kept centrally st ored

and locked for two residents who required assistance with self -

administration of medication , and failing to ensure that

abandoned and expired medications were destroyed or returned to

the pharmacy, in violation of rule 58A - 5.0185(6). Both of these

fa ilures concerned an unlocked cabinet in the back structure.

AHCA cited that violation as a class III deficiency and gave

Blue Angel 30 days to correct it.

77. Based on the findings of fact and ultimate fact above,

AHCA established by clear and convincing evidence that Blue

Angel violated rule 58A - 5.0185(6) by failing to keep the

centrally - stored medication cabinet in the back structure locked

and properly dispose of the expired medications found therein. 8 /

78. However, based on the findings of fact and u ltimate

fact above, AHCA did not establish by clear and convincing

evidence that Blue Angel failed to correct that cited deficiency

within 30 days. Blue Angel corrected that cited deficiency by

removing and properly disposing of all medication from the

ca binet in the back structure before the revisit survey. As

such, Ða fine may not be imposed.Ñ £ 408.813(2)(c), Fla. Stat.

79. Albeit in the same general subject matter, the

deficiency cited after the revisit survey concerned a different

cabinet in an ent irely separate building. Those distinctions

matter here. See A g . for Health Care Admin. v. Tampa Health

Care Associates, LLC , Case No. 03 - 165 (Fla. DOAH May 30, 2003;

Fla. AHCA Nov. 14, 2003) (finding fine inappropriate based on

failure to timely correct a deficiency because initial survey

cited one broken laundry shoot door, which had been fixed, but

revisit survey cited a different broken laundry shoot door).

Count V - $500 Fine for Lack of Background Screening

80. AHCA seeks to impose an administrat ive fine for Blue

AngelÓs failure to ensure that a level II background screening

had been completed for one of its employees who resided in the

facility and provided care to its residents, as required by

section 408.809(1) - (2). AHCA seeks to impose a $500 fine for

this violation pursuant to sections 429.19(2)(e) and

408.813(3)(b).

81. Blue Angel admitted to the allegations in Count V and

to the $500 administrative fine imposed therein.

Count VI - $500 Fine for Overcapacity

82. AHCA seeks to impose an administrative fine of $500

for Blue Angel operating over its 6 - bed capacity in violation of

section 408.813(3). AHCA alleged that Resident 1 lived at Blue

Angel along with six other residents and that, as such, it was

operating beyond its licensed six - be d capacity.

83. Blue Angel admitted to the allegations in Count VI and

to the $500 administrative fine imposed therein.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Agency for Health Care

Admi nistration issue a final order revoking the license (#12211)

of Blue Angel Enterprises, Inc., d/b/a Blue Angel Residences,

and imposing an administrative fine totaling $2,500.

DONE AND ENTERED this 5th day of July , 2019 , in

Tallahassee, Leon County, Florid a.

S

ANDREW D. MANKO

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 5th day of July , 2019 .

ENDNOTE S

1/ All statutory references are to Florida Statutes (2018),

unless otherwise noted.

2/ AHCA filed both un - redacted and redacted versions of all of

it s exhibits to protect the confidentiality of the residents .

The un - redacted exhibits, including a demonstrative aid that

identifies the names of the residents and staff with their

corresponding resident number or staff letter, have been sent

back to AHCA in a sealed box labelled to indicate that the

contents are confidential.

3/ Consistent with section 120.57(1)(c), the undersigned has not

based any finding of fact on hearsay evidence alone, unless it

would be admissible over objection in a civil act ion or merely

supplements or explain s other admissible evidence.

For example, AHCA introduced its survey notes into evidence,

which contain both notes of what the surveyors observed during

their investigations and summaries of out - of - court statement s

made by Blue AngelÓs staff, residents , and family members to the

surveyors. The records constitute hearsay and, in some cases,

hearsay within hearsay. However, the survey notes themselves

are admissible under the public records exception, as they are

r ecords created by AHCA pursuant to a duty to report and contain

observations made by the surveyors during their investigation.

§ 90.803(8), Fla. Stat. Summaries of the out - of - court

statements made by Blue AngelÓs staff and Ms. Aussendorf to the

surveyors are admissible as party admissions. See § 90.803(18),

Fla. Stat. (providing that statements made either by a party or

by a partyÓs servant about a matter within the scope of

employment are admissible as admissions). Although the

summaries of the stateme nts made by the residents and family

members to the surveyors are hearsay (as is any testimony by

surveyors as to what residents or family members told the m ),

they supplement and explain other admissible evidence, including

the multitude of records maintai ned in Blue AngelÓs files , i.e. ,

residential leases, medication logs, and medical records

documenting the needs of the residents , that detail the types of

services being provided to the residents.

4/ The testimony and exhibits revealed the following co nflicting

evidence.

As to Resident 13, Ms. Evans testified that she was

discharged from Blue Angel to a private house on January 18,

2018, based on her interview with Blue AngelÓs staff and her

conversations with staff from KristianaÓs ALF and Resid ent 13

herself. The survey notes indicate that both a fri end of

Resident 13 and her long - term care case manager, Ms. Lawrence,

told Ms. Evans that she had been living at Orchard Hills ALF for

several weeks and that staff at KristianaÓs ALF told Ms. Evans

she arrived on February 13, 2018. Ms. Lawrence testified that

she moved Resident 13 from Blue Angel to KristianaÓs ALF around

February 13, 2018, though she only visited her once a week and

could not confirm whether Resident 13 was only at Blue Angel on

th e days she visited. Ms. Bonoan, the administrator of

KristianaÓs ALF, also testified that Resident 13 was admitted on

February 13, 2018, though she did not know the name of the ALF

from which Resident 13 came and could not confirm that it was

Blue Angel.

As to Resident 14 , Ms. Evans testified that she moved to

another ALF on January 18, 2018. Yet, the survey notes indicate

that Ms. Evans spoke with the administrator for Rose and Mary

ALF, who confirmed that Resident 14 moved there on January 23,

2018 .

As to Resident 15 , Ms. Evans testified that she moved out to

live with family on January 23, 2018. The survey notes confirm

that Resident 15Ós daughter told Ms. Evans that her mother had

been with her in Tennessee for two to three weeks.

As to Resident 16 , Ms. Evans testified that she moved to

another ALF on January 16, 2018. Yet, the survey notes indicate

that Ms. Evans spoke with the administrator for Rose and Mary

ALF, who confirmed that Resident 1 6 moved there on January 23,

2018.

5 / I n what appear to be mere typos, AHCA cited section

408.805(1)(c) as a basis for license revocation in Count II and

section 408.815(1)(c) as a basis for imposing an administrative

fine in Count III . However, section 408.805 concerns licensure

fees, not rev ocation, and there is no subsection (1)(c) therein.

AHCA again mistakenly cited section 408.805(1)(c) at the hearing

as grounds for revocation, but made it clear that it was

pursuing revocation on grounds that Blue AngelÓs controlling

interest violated ch apter 408 and other governing statutes and

rules. The statute that authorizes revocation on that basis is

section 408.815(1)(c), which is just one number off from AHCAÓs

citations. Similarly, AHCA cited section 408.815(1)(c) as one

of the bases for impos ing the fine in Count III (it also

properly cited section 429.19(2)(e)), rather than citing section

408.813(3)(b), as it correctly did in Counts IV, V, and VI .

However, Blue Angel did not argue lack of notice or raise any

issue as to these apparent typos at any point during th is case .

6 / At the beginning of the final hearing, AHCA renewed its pre -

hearing motion to determine no justiciable issues of material

fact as to Count I. The basis for AHCAÓs motion is that, on

January 16, 2018, Blue Angel filed an application to increase

its capacity from six to ten beds in the main building.

Although the timing of this application happened to coincide

with the complaint survey, Blue Angel had sought approval from

the zoning board in early 2017 to increase its b ed capacity and

had been unable to file the application until it received zoning

approval in December 2017. The application did not seek to

convert or license the back structure. On April 12, 2018, AHCA

denied the application for six reasons, including t hat the

complaint survey uncovered unl icensed activity. On June 1,

2018, AHCA issued a final order denying the application.

Because Blue Angel neither requested a hearing on the denial

of its application nor appealed AHCAÓs fi nal order after it was

issued, AHCA argues that the findings made in its notice of

denial and final order concerning the unlicensed activity were

entitled to res judicata effect on Count I in this proceeding,

which are based on those violations. The undersigned denied

this moti on before the hearing without prejudice to re - raising

it after all of the evidence had been presented.

Although AHCA renewed its motion at the beginning of the

final hearing, it failed to re - raise the issue during closing

arguments after the evidenc e had been presented or include any

argument about it in its PRO. Thus, AHCA waived this issue.

Even if the issue had been preserved, the motion would be

denied. AHCA failed to introduce the notice of denial or the

final order into evidence , both of which are necessary to make

findings of fact on the issue of res judicata . AHCA did not

request that official recognition be taken of either document

and merely attaching copies of them t o its pre - hearing motion is

insufficient to rely on them as evidenc e in this matter .

Regardless, the denial of the motion would stand for the

same reasons explained in the pre - hearing O rder dated

February 27, 2019. Res judicata may be applied in

administrative proceedings, but only with Ðgreat caution.Ñ

Thomson v. DepÓt of Env tl . Reg. , 511 So. 2d 989, 991 (Fla.

1987). Because of the fluidity of facts and shifting policies

of government work, res judicata will not apply if there are

Ðnew facts, changed conditions, or additional submissionsÑ by

the non - governmental e ntity. See id. (holding that res judicata

did not apply to second application for permit because first

application was denied on somewhat different grounds and second

application changed the location of the dock); Delray Med. Ctr.

v. Ag. for Health Care A dmin. , 5 So. 3d 26, 29 (Fla. 4th DCA

2009) (noting that ÐFlorida courts do not apply the doctrine of

administrative finality when there has been a significant change

of circumstances or there is a d emonstrated public interestÑ).

As the First District Cour t of Appeal recognized:

This doctrine bars relitigation of an issue

when the following five factors are met:

"(1) an identical issue must have been

presented in the prior proceeding; (2) the

issue must have been a critical and

necessary part of the prior determination;

(3) there must have been a full and fair

opportunity to litigate that issue; (4) the

parties in the two proceedings must be

identical; and (5) the issue[] must have

been actually litigated.Ñ

Felder v. DepÓ t of Mgmt. Servs., Div. of Ret. , 9 93 So. 2d 1031,

1034 (Fla. 1st DCA 2008) (quoting Goodman v. Aldrich & Ramsey

Enters., Inc. , 804 So. 2d 544, 546 - 47 (Fla. 2d DCA 2002)).

In this case, AHCA seeks to use its unchallenged findings in

denying Blue AngelÓs application to increase its capacity as res

judicata for the facts underlying its attempt to impose

administrative fines in Count I and revoke Blue AngelÓs license

in Count II. However, these two matters are distinct (denial of

an application vs. revo cation of a license), the standards and

b urdens of proof are quite different, and AHCAÓs denial of the

application was based on four factors beyond the unlicensed

activity . Even t he factual findings as to unlicensed activity

in the n otice of i ntent were not specific . In sum, t he critical

differ ences between the two matters and the burdens of proof,

and the lack of specificity of the prior findings render res

judicata inapplicable in this instance.

7 / The undersigned rejects Blue AngelÓs argument that a fine

would be improper because AHCA faile d to consider the factors

outlined in section 429.19(3). T hose factors are required to be

considered only when AHCA imposes a fine under section 429.19.

Here, AHCA seeks to impose a fine under sections 408.812,

408.815, and 429.14, none of which contain the factors outlined

in section 429.19(3). Accordingly, section 429.19(3) is

inapplicable here.

8 / The undersigned rejects Blue AngelÓs argument that it cannot

be fined for its admitted failure to keep centrally - stored

medications locked in a cabinet b ecause the back structure was

not a licensed facility that had such a requirement. Not only

is this argument made solely in the conclusion section of its

PRO with no citation to supporting legal authority, but the

findings of fact and conclusions of law a bove confirm that Blue

Angel was operating an ALF and was required to comply with the

legal requirements for doing so, notwithstanding that it was

unlawfully operating without a license.

COPIES FURNISHED:

Nicola Brown, Esquire

Agency for Health Car e Administration

Suite 330H

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

(eServed)

Jeffrey Scott Howell, Esquire

Jeffrey S. Howell, P.A.

2898 - 6 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Rickey L. Strong, Esquire

Jeffrey S. Howell, P .A.

2898 - 6 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Gisela Iglesias, Esquire

Agency for Health Care Administration

Suite 330G

525 Lake Mirror Drive North

St. Petersburg, Florida 33701

(eServed)

John Thomas Buchan, Esquire

Jeffrey S. Howell, P.A .

2898 - 6 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Richard J. Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Kim Kellum, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Thomas M . Ho e ler, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Mary C. Mayhew, Secretary

Agency for Health Care Adm inistration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 32308

(eServed)

Stefan Grow, General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.