98-004688 Agency For Health Care Administration vs. New Horizon`s Adult Living, Inc. Status: Closed Recommended Order on Tuesday, April 6, 1999.

Summary: $3,000 in fines against assisted living facility for various deficiencies.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Petitioner, )

)

vs. ) Case No. 98-4688

) (8-98-279-ALF)

NEW HORIZON'S ADULT LIVING, )

INC., )

)

Respondent. )

______________________________)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Petitioner, )

)

vs. ) Case No. 98-4689

) (8-98-288-ALF)

NEW HORIZON'S ADULT LIVING, )

INC., )

)

Respondent. )

______________________________)

RECOMMENDED ORDER

Robert E. Meale, Administrative Law Judge of the Division of

Administrative Hearings, conducted the final hearing in Port

Charlotte, Florida, on February 3, 1999.

APPEARANCES

For Petitioner: Karel Baarslag

Senior Attorney

Agency for Health Care

Administration

State Regional Service Center

2295 Victoria Avenue

Fort Myers, Florida 33901

For Respondent: Violeta D. Sebastian

Qualified Representative

New Horizon's Adult Living Facility

1391 Capricorn Boulevard

Punta Gorda, Florida 33983

STATEMENT OF THE ISSUE

The issues are whether Respondent is guilty of various

deficiencies found during surveys of its adult living facility

and, if so, the amount of the administrative fines.

PRELIMINARY STATEMENT

In DOAH Case No. 98-4688 , an Administrative Complaint dated

August 4, 1998, alleges that Respondent provided care for a

resident whose needs exceeded the scope of Respondent's license,

in violation of Section 400.447(1), Florida Statutes, and Rule

58A-5.0184(1), Florida Administrative Code, for which Petitioner

sought a $500 fine (Tag A 006).

In DOAH Case No. 98-4689, an Administrative Complaint dated

October 2, 1998, alleges that Respondent failed to provide the

required financial accountings due one resident, in violation of

Section 400.427(4), Florida Statutes, and Rule 58A-5.021(2)(c)2,

Florida Administrative Code, for a fine of $300 (Tag A 102);

failed to have a current Radon test, in violation of Section

404.056, Florida Statutes, and Rule 58A-5.023(19), Florida

Administrative Code, for a fine of $100 (Tag A 202); failed to

include the correct information in their facility contract and,

during one survey, lacked a facility contract, in violation of

Sections 400.431(3) and 400.424(1) -(3)(a), Florida Statutes, for

a fine of $300 (Tag A 303); failed to follow the provisions of

the facility contract, in violation of Rule 58A-5.024(2)(b),

Florida Administrative Code, for a fine of $300 (Tag A 304);

failed to obtain one resident's health assessment within the

required time, in violation of Section 400.426(4) and (5),

Florida Statutes, and Rule 58A-5.0181(3)(a)1 and 2, Florida

Administrative Code, for a fine of $300 (Tag A 401); allowed

residents to continue to reside at the facility after they no

longer met the criteria for continued placement, in violation of

Rule 58A -5.0181(1)(a) and (e), Florida Administrative Code, for a

fine of $1000 (Tag A 407); allowed a resident to continue to

reside at the facility after the resident no longer met the

criteria for continued placement, in violation of Section

400.426(8), Florida Statutes, and Rule 58A-5.0181(8), Florida

Administrative Code, for a fine of $1000 (Tag A 409); failed to

train two of four staff in responding to the needs of the

residents, in violation of Rule 58A-5.0191(4)(a)-(e) and 7,

Florida Administrative Code, for a fine of $300 (Tag A 504);

failed to train two of four staff on personal hygiene and

assistance of residents with the activities of daily living, in

violation of Rule 58A-5.0191(5)(a) and (b), Florida

Administrative Code, for a fine of $300 (Tag A 505); failed to

designate a staff person to be in charge of medications, in

violation of Rule 58A-5.0182(6)(b)1 and 2.b, Florida

Administrative Code, for a fine of $300 (Tag A 602); failed to

keep all medications in a locked area at all times, in violation

of Rule 58A-5.0182(6)(d)3.a-d, Florida Administrative Code, for a

fine of $300 (Tag A 607); failed to provide services appropriate

to the residents' needs, in violation of Rule 58A-5.0182(2),

Florida Administrative Code, for a fine of $1000 (Tag A 700); and

used physical restraints on residents, in violation of Rule

58A -5.0182(8) and (9), Florida Administrative Code, for a fine of

$1000 (Tag A 709).

At the hearing, the Administrative Law Judge struck the

allegations underlying Tags A 303 and A 304, which concern the

facility contract, because the record contains no copy of the

contract.

At the hearing, Petitioner called two witnesses and offered

into evidence one exhibit. Respondent called one witness and

offered into evidence one exhibit. Both exhibits were admitted.

The Administrative Law Judge left the exhibits with

Petitioner's counsel for copying, but he did not file them with

the Division of Administrative Hearings. Petitioner's exhibit

was a copy of a survey, and Respondent's exhibit was a copy of an

accounting. The Administrative Law Judge closely examined both

of these exhibits at the hearing, so their omission from the

record is immaterial for the purpose of preparing this

Recommended Order. If the parties desire, they may add the

exhibits to the file after the issuance of the Recommended Order.

The court reporter filed the Transcript on March 11, 1999.

FINDINGS OF FACT

1. Pursuant to a license issued by Petitioner, Respondent

owns and operates New Horizon, an assisted living facility in

Punta Gorda. The license is a standard license. Violeta

Sebastian is the owner and president of Respondent and the

administrator of the facility.

2. On July 8, 1998, Petitioner conducted a survey of New

Horizon. Petitioner's investigator found several residents

sitting in the day room when he arrived at the facility between

9:00 a.m. and 9:30 a.m.

3. Resident Number 3, who is very elderly, remained seated

in an over-stuffed chair all morning. When staff helped her to

the dining room at around 11:30 a.m., the investigator asked to

see her buttocks area and found a Stage 2 pressure sore on the

coccyx area. Resident Number 3, who was wearing adult briefs,

had also urinated on herself at some earlier point in time.

4. Resident Number 3 required the assistance of two

staffpersons to get her to stand; she was unable to assist in

this process. She also required the assistance of both

staffpersons to walk, and she required complete assistance to

change her briefs.

5. The records concerning Resident Number 3 revealed

nothing about the existence or treatment of a pressure sore or

that staff had notified the resident's physician. An aide knew

of the pressure sore for three days, but had not informed the

administrator nor commenced treatment.

6. The records also revealed that she was admitted to New

Horizon on August 28, 1997, and her health assessment was

conducted on September 29, 1997, which was 32 days after

admission.

7. A Stage 1 pressure sore is a reddened area. A Stage 2

pressure sore is a reddened area with a blister. A Stage 3

pressure sore occurs when the affected area is open to the

muscle. A Stage 4 pressure sore is when the affected area is

open to the muscle, bone, and tendon.

8. Stage 2 pressure sores are susceptible to infection and

may cause a loss of fluids, including protein, around the wound

site. The pressure sore on this female resident was about two

centimeters wide.

9. As a result of these findings concerning Resident Number

3, Petitioner cited Respondent for Tags A 006, A 401, A 407,

A 409, and A 700.

10. Another investigator asked for the most current Radon

test. The last Radon test, which the facility passed, was

November 16, 1992, which meant that the facility had not been

tested in almost five years and eight months.

11. As a result of these findings, Petitioner cited

Respondent for Tag A 202.

12. The investigator checked the training records for two

of four staffpersons and determined that two employees had not

received the two hours' required training in resident behavior

and handling abuse, neglect, and exploitation. The administrator

thought that they had received the required training, but was

unable to produce documentation of training.

13. As a result of these findings, Petitioner cited

Respondent for Tag A 504.

14. The investigator checked the training records for four

staffpersons and determined that they had not received the

required training in assisting residents in the activities of

daily living. The administrator said that this was an oversight

and would be corrected.

15. As a result of these findings, Petitioner cited

Respondent for Tag A 505.

16. The investigator could not determine who was in charge

of medications. However, the administrator and one part-time

employee were in charge of medications.

17. As a result of these findings, Petitioner cited

Respondent for Tag A 602.

18. The investigator found a bottle of milk of magnesia in

an unlocked refrigerator and a bag of medications in an unlocked

kitchen drawer.

19. As a result of these findings, Petitioner cited

Respondent for Tag A 607.

20. The investigator testified as to restraints of a

resident found by another investigator in a 1996 survey and found

by her in a 1998 complaint investigation. However, her testimony

concerning the incident of which she had personal knowledge was

vague and provides an insufficient basis on which to fine

Respondent.

21. As a result of these findings, Petitioner cited

Respondent for Tag A 709.

22. The investigator examined a ledger maintained by

Respondent for one resident who was receiving certain federal

benefits in the form of a monthly $35 check. Respondent's

records do not document that it supplies the resident quarterly

with a copy of this accounting, and staff and the administrator

admitted to not supplying quarterly statements to the resident.

23. As a result of these findings, Petitioner cited

Respondent for Tag A 102.

24. Petitioner did not produce admissible evidence to show

that any violations were repeat violations.

CONCLUSIONS OF LAW

25. The Division of Administrative Hearings has

jurisdiction over the subject matter. Section 120.57(1), Florida

Statutes. (All references to Sections are to Florida Statutes.

All references to Rules are to the Florida Administrative Code.)

26. Petitioner must prove the material allegations by clear

and convincing evidence. Department of Banking and Finance v.

Osborne Stern and Company, Inc. , 670 So. 2d 932 (Fla. 1996) and

Ferris v. Turlington , 510 So. 2d 292 (Fla. 1987). However, the

findings would be the same if the preponderance standard applied.

27. Section 400.426 provides in part:

(4) If possible, each resident shall have

been examined by a licensed physician or a

licensed nurse practitioner within 60 days

before admission to the facility. The signed

and completed medical examination report

shall be submitted to the owner or

administrator of the facility who shall use

the information contained therein to assist

in the determination of the appropriateness

of the resident's admission and continued

stay in the facility. The medical

examination report shall become a permanent

part of the record of the resident at the

facility and shall be made available to the

agency during inspection or upon request. An

assessment that has been completed through

the Comprehensive Assessment and Review for

Long-Term Care Services (CARES) Program

fulfills the requirements for a medical

examination under this subsection and s.

400.407(3)(b)6.

(5) Except as provided in s. 400.407, if a

medical examination has not been completed

within 60 days before the admission of the

resident to the facility, a licensed

physician or licensed nurse practitioner

shall examine the resident and complete a

medical examination form provided by the

agency within 30 days following the admission

to the facility to enable the facility owner

or administrator to determine the

appropriateness of the admission. The

medical examination form shall become a

permanent part of the record of the resident

at the facility and shall be made available

to the agency during inspection by the agency

or upon request.

(8) If, at any time after admission to a

facility, a resident appears to need care

beyond that which the facility is licensed to

provide, the agency shall require the

resident to be physically examined by a

licensed physician or licensed nurse

practitioner. This examination shall, to the

extent possible, be performed by the

resident's preferred physician or nurse

practitioner and shall be paid for by the

resident with personal funds, except as

provided in s. 400.418(1)(b). Following this

examination, the examining physician or

licensed nurse practitioner shall complete

and sign a medical form provided by the

agency. The completed medical form shall be

submitted to the agency within 30 days after

the date the facility owner or administrator

is notified by the agency that the physical

examination is required. After consultation

with the physician or licensed nurse

practitioner who performed the examination, a

medical review team designated by the agency

shall then determine whether the resident is

appropriately residing in the facility. The

medical review team shall base its decision

on a comprehensive review of the resident's

physical and functional status, including the

resident's preferences, and not on an

isolated health-related problem. In the case

of a mental health resident, if the resident

appears to have needs in addition to those

identified in the community living support

plan, the agency may require an evaluation by

a mental health professional, as determined

by the Department of Children and Family

Services. A facility may not be required to

retain a resident who requires more services

or care than the facility is able to provide

in accordance with its policies and criteria

for admission and continued residency.

Members of the medical review team making the

final determination may not include the

agency personnel who initially questioned the

appropriateness of a resident's placement.

Such determination is final and binding upon

the facility and the resident. Any resident

who is determined by the medical review team

to be inappropriately residing in a facility

shall be given 30 days' written notice to

relocate by the owner or administrator,

unless the resident's continued residence in

the facility presents an imminent danger to

the health, safety, or welfare of the

resident or a substantial probability exists

that death or serious physical harm would

result to the resident if allowed to remain

in the facility.

28. Section 400.427(4) provides:

Any funds or other property belonging to or

due to a resident, or expendable for his or

her account, which is received by a facility

shall be trust funds which shall be kept

separate from the funds and property of the

facility and other residents or shall be

specifically credited to such resident. Such

trust funds shall be used or otherwise

expended only for the account of the

resident. At least once every 3 months,

unless upon order of a court of competent

jurisdiction, the facility shall furnish the

resident and his or her guardian, trustee, or

conservator, if any, a complete and verified

statement of all funds and other property to

which this subsection applies, detailing the

amount and items received, together with

their sources and disposition. In any event,

the facility shall furnish such statement

annually and upon the discharge or transfer

of a resident. Any governmental agency or

private charitable agency contributing funds

or other property to the account of a

resident shall also be entitled to receive

such statement annually and upon the

discharge or transfer of the resident.

29. Section 400.447(1) provides:

It is unlawful for any person or public body

to offer or advertise to the public, in any

way by any medium whatever, personal services

as defined in this act, without obtaining a

valid current license. It is unlawful for

any holder of a license issued pursuant to

the provisions of this act to advertise or

hold out to the public that it holds a

license for a facility other than that for

which it actually holds a license.

30. Section 404.056(5) provides:

(5) Mandatory testing.--All public and

private school buildings or school sites

housing students in kindergarten through

grade 12; all state-owned, state-operated,

state-regulated, or state-licensed 24-hour

care facilities; and all state-licensed day

care centers for children or minors shall be

measured to determine the level of indoor

radon, using measurement procedures

established by the department. Initial

measurements shall be completed and reported

to the department by July 1, 1990, and

repeated measurements shall be performed and

reported to the department at 5-year

intervals. . . .

31. Rule 58A-5.0181 provides in part:

(1) In order to be admitted to any facility,

an individual shall meet the following

criteria:

(a) The individual is able to perform the

activities of daily living, with supervision

or assistance if necessary.

(e) The individual has no bedsores or skin

breaks classified by a health care provider

as stage 2, 3, or 4 pressure ulcers.

(3) Admission procedures are as follows:

(a) Residents not placed by the

department, by HRS, or by an agency under

contract with the department or HRS.

1. Each resident, in accordance with

Section 400.426(4), F.S., shall be examined

by a health care provider within 60 days

before admission to the facility. The

medical examination report shall be submitted

to the administrator of the facility, who

shall use the information therein to assist

in the determination of the appropriateness

of admission of the resident to the facility.

2. If a medical examination has not been

completed within 60 days prior to the

resident's admission to the facility, a

health care provider shall examine the

resident and complete an assessment report

using the Health Assessment for Assisted

Living Facilities, DOEA Form 1823, dated

October 1995, which is hereby incorporated by

reference, within 30 days following the

resident's admission to the facility, to

enable the administrator to determine the

appropriateness of admission. . . .

(8) The administrator is responsible for

monitoring the continued appropriateness of

placement of a resident in the facility.

32. Rule 58A-5.0182 provides in part:

(2) Facilities shall offer personal

supervision, as appropriate for each

resident, including the following as needed:

(a) Supervision of diets as to quality and

quantity, including documentation of the

resident's refusal to comply with a

therapeutic diet and notification to the

health care provider of such refusal.

However, a competent individual shall not be

compelled to follow a restrictive diet. If a

resident refuses to follow a therapeutic diet

after the benefits are explained, a signed

statement from the resident refusing the

therapeutic diet is acceptable documentation

of a resident's preferences. In such

instances, daily documentation is not

necessary.

(b) Daily observation by designated staff

of the activities of the resident while on

the premises and daily awareness of the

general health, safety, and physical and

emotional well-being of the individual.

(c) Awareness of the resident's general

whereabouts, although the resident may travel

independently in the community.

(d) Encouragement of residents to

participate in social, recreational,

vocational, treatment services, and other

activities within the community and the

facility.

(e) Promptly noting in the resident's

personal record any apparent deviations from

his normal appearance or state of health or

well-being.

(f) Contacting the resident's family,

guardian, health care surrogate, or health

care provider and case manager or mental

health case manager when a resident exhibits

a significant change, when the resident moves

out of the facility, or when there is an

emergency, in accordance with written

procedures.

* * *

(6)(b) Supervision of self-administered

medication.

1. A staff person, designated in

writing, who is at least 18 years of age and

who has access to, is responsible for, and is

trained in the supervision of self-

administered medications in accordance with

Rule 58A-5.0191, shall be available at all

times.

2. The designated staff person shall

supervise the self-administered medication in

the following manner:

b. Ensure that the medication is

given to the resident for whom it is

prescribed at the time indicated on the

prescription.

(d)3. Centrally stored medications shall be:

a. Kept in a locked cabinet or other

locked storage receptacle or area at all

times.

b. Accessible only to the staff

responsible for supervision of self-

administration and for administration of

medication. Such staff shall have ready

access to keys to medication storage areas at

all times.

c. Located in an area free of

dampness and abnormal temperature, except

that a medication requiring refrigeration

shall be refrigerated. Refrigerated

medications shall be secured by being kept in

a locked container within the refrigerator,

by keeping the refrigerator locked, or by

keeping the area in which refrigerator is

located locked.

d. Each container of medication

shall be kept closed or sealed.

(8) No resident shall be held in a facility

against his will, unless it is necessary for

his personal protection while awaiting law

enforcement or professional help.

(9) Physical restraints. Physical

restraints shall not be used in facilities.

However, half-bedside rails, when used only

as half-bedside rails, shall be used only

upon the written order of the resident's

health care provider, who shall review the

order at least every 6 months. Any device

which the resident chooses to use and can

remove without assistance shall not be

considered a restraint.

33. Rule 58A-5.0184(1) provides: "No facility shall hold

itself out to the public as providing any services other than

those consistent with the license it has."

34. Rule 58A-5.0191 provides in part:

(4) FIRST AID AND CARDIOPULMONARY

RESUSCITATION (CPR). A staff member who has

completed courses in First Aid and CPR and

holds a currently valid card documenting

completion of such courses must be in the

facility at all times.

(a) Documentation of attendance at First

Aid or CPR course offered by an accredited

college, university or vocational school; a

licensed hospital; the American Red Cross,

American Heart Association, or National

Safety Council; or if offered by a provider

approved by a health-related professional

board in the Department of Health, shall

satisfy this requirement.

(b) Other courses taken in fulfillment of

this requirement must meet the following

criteria and be approved and documented in

accordance with subsection (10) of this rule:

1. First Aid training must be a minimum

of 3 hours and cover disease transmission;

care of abrasions, scratches, cuts, and

insect bites; care of wounds; control of

bleeding; identification and care for

injuries to muscles, bones and joints; care

of burns; care for hypothermia and heat

related illnesses; management of seizures;

identification and care for injuries to the

head and spine; when to move victims with

injuries; and poison control. Persons

providing First Aid training must:

a. Hold a current First Aid

instructor's card from the American Red

Cross, the National Safety Council, or an

accredited university; or

b. Be a registered nurse with a

minimum of 1 year's experience in long-term

or acute care or 1 year's teaching experience

in a health-related topic; or emergency

medical technician or paramedic currently

certified under part III of chapter 401,

F.S., with a minimum of 1 year's teaching

experience in a health-related topic.

2. CPR training must be a minimum of 3

hours; include the opportunity for "hands on"

learning through practice exercises; and be

in accordance with the recommendations of the

1992 Conference on Cardiopulmonary

Resuscitation and Emergency Cardiac Care,

American Health Association, published in the

Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiac Care, I and II, JAMA,

1992;268:2172-2198, which is incorporated by

reference. Persons providing CPR training

must hold a current CPR instructor's card

from the American Red Cross, the American

Heart Association, or National Safety

Council.

(c) A nurse shall be considered as having

met the training requirement for First Aid.

An emergency medical technician or paramedic

currently certified under part III of chapter

401, F.S., shall be considered as having met

the training requirements for both First Aid

and CPR.

(5) SUPERVISION OF SELF-ADMINISTERED

MEDICATION. Persons designated to supervise

the self-administration of medication

pursuant to Rule 58A-5.0182 must receive a

minimum of 2 hours of training prior to

assuming this responsibilityaining must

cover state law and rule requirements with

respect to the supervision, administration,

and management of medications in facilities,

procedures for assisting the resident with

self-administration of medication, common

medications, recognition of side effects and

adverse reactions and procedures to follow

when residents appear to be experiencing side

effects and adverse reactions, documentation

and record keeping, and medication storage.

Completion of the core training program shall

satisfy this requirement. Other courses

taken in fulfillment of this requirement must

be documented in accordance with this rule.

(7) EXTENDED CONGREGATE CARE TRAINING.

(a) The administrator and extended

congregate care supervisor, if different from

the administrator, must complete core

training and 6 hours of initial training in

extended congregate care provided by the

department prior to the facility's receiving

its extended congregate care license or

within 3 months of beginning employment in

the facility. Completion of core training

shall be a prerequisite for this training.

Supervisors who attended core training prior

to April 20, 1998, shall not be required to

take the core training competency test.

(b) The administrator and the extended

congregate care supervisor, if different from

the administrator, must complete a minimum of

6 hours of continuing education every two

years in any of the core topics identified in

s. 400.452, F.S.; or physical, psychological,

or social needs of frail elderly and disabled

persons, or persons with Alzheimer's disease

or related disorders.

(c) All direct care staff employed in a

facility licensed to provide extended

congregate care must complete at least 6

hours of in-service training provided by the

facility within 6 months of beginning

employment in the facility. The training

must address extended congregate care

concepts and requirements, including

statutory and rule requirements, and delivery

of personal care and supportive services in

an extended congregate care facility.

35. Rule 58A-5.021(2)(c)2 provides that "the facility

shall":

(c) Assure that facility staff manage, use,

and dispose of residents' property as

provided by law in Section 400.427, F.S.

2. Statements of resident trust funds,

including any property held for safekeeping,

shall be sent at least quarterly to the

resident, guardian, individual holding a

power of attorney, or resident

representative, with copies maintained in the

resident's file.

36. Rule 58A-5.023(19) provides: "Indoor radon testing as

mandated by Section 404.056, F.S., shall be completed by all

facilities."

37. Petitioner has proved the following tags with the

corresponding fines: A 401--$300; A 407--$1000 (due to inability

of Resident Number 3 to do certain activities of daily living and

the presence of a pressure sore); A 700--$1000 (due to failure to

make prompt notation of pressure sore in records of Resident

Number 3 and contact the family or health care provider after

significant change in condition of Resident Number 3);

A 202 - -$100; A 607--$300; and A 102--$300.

38. Petitioner failed to prove the remaining tags for the

noted reasons: A 006 (prohibition against facility holding

itself out in certain way; no evidence that Respondent held

itself out in any fashion); A 409 (requirement of 30 days' notice

prior to relocation of resident; no evidence that Respondent

proposed relocation of Resident Number 3, and Petitioner's theory

for this tag duplications Tag A 700); A 504 (administrator denied

training deficiency; no other admissible evidence of deficiency);

A 505 (administrator admitted oversight concerning training, but

cited authority is predicated on the designation of staffperson

to supervise self-administration of medications, and evidence

failed to establish such a designation among any of the untrained

staff); A 602 (lack of evidence); and A 709 (lack of evidence).

RECOMMENDATION

It is

RECOMMENDED that the Agency for Health Care Administration

enter a final order imposing an administrative fine against New

Horizon's Adult Living, Inc., in the amount of $3000.

DONE AND ENTERED this 6th day of April, 1999, in

Tallahassee, Leon County, Florida.

___________________________________

ROBERT E. MEALE

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

[phone] SUNCOM 278-9675

Fax Filing [phone]

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 6th day of April, 1999.

COPIES FURNISHED:

Ruben J. King-Shaw, Jr., Director

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317-4229

Paul J. Martin, General Counsel

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317-4229

Sam Power, Agency Clerk

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317-4229

Karel Baarslag, Senior Attorney

Agency for Health Care

Administration

State Regional Service Center

2295 Victoria Avenue

Fort Myers, Florida 33901

Violeta D. Sebastian

Qualified Representative

New Horizon's Adult Living Facility

1391 Capricorn Boulevard

Punta Gorda, Florida 33983

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 must be filed with the agency that will

issue the final order in this case.