16-003253 Gv Dade City, Llc, D/B/A Edwinola Retirement Community vs. Agency For Health Care Administration Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Wednesday, June 22, 2016.

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

2016NL- -!

GV DADE CITY, LLC, d/ b / a P 3:(:) 3

EDWINOLA RETIREMENT COMMUNITY,

Petitioner,

v AHCA NO. 2016002593

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Respondent.

FINAL ORDER

Having reviewed the Notice of Intent to Deny Change of Ownership Application, and all other

matters of record, the Agency for Health Care Administration finds and concludes as follows:

1. The Agency issued the Petitioner, a change of ownership applicant for Assisted Living

Facility licensure, the attached Notice of Intent to Deny and Election of Rights form. ( Ex. 1) The

Election of Rights form advised the Petitioner of the right to an administrative hearing pursuant to

Sections 120. 57( 1) and 120. 57( 2), Florida Statutes.

2. The Petitioner voluntarily withdrew its change of ownership application. ( Ex. 2)

Based upon the foregoing, it is ORDERED:

3. The Petitioner' s change of ownership application for licensure is WITHDRAWN.

ORDERED at Tallahassee, Florida, on this 30 day of , 2016.

d

ElizabW Dudek, kcretary

Agency for Health Care Administration

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled to judicial review, which shall be

instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy,

along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district

where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be

conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30

days of rendition of the order to be reviewed.

CERTIFICATE OF SERVICE

I CERTIFY that a true and correct copy of this F' al Order was served on the below - named

persons by the method designated on this '" day of , 2016.

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Bldg. # 3, Mail Stop # 3

Tallahassee, Florida 32308 - 5403

Telephone: ( 850) 412 - 3630

Facilities Intake Unit Craig H. Smith, Esquire

Agency for Health Care Administration Hogan Lovells US LLP

Electronic Mail) 215 South Monroe Street

Tallahassee, FL 32301

U. S. Mail)

rtified Article Number RICK SCOTT

GOVERNOR

SENDERS RECORD ELIZABETH DUDEK

P SECRETARY

March 11, 2016 CERTIFIED

Darcielle Gray, Administrator File Number: 11953430

GV Dade City LLC, D. B. A Edwinola Retirement License Number: 7295

Community

14235 Edwinola Way Provider Type: assisted living facility

Dade City, FL 33525

RE: Complaint Number 2016002593 14235 Edwinola Way, Dade City

Notice Of Intent To Deny for Change of Ownership ( CHOW) Application

It is the decision of this Agency that Edwinola Retirement Community' s Change of Ownership

application for ( an / the) assisted living facility license be DENIED.

The Specific Basis for this determination is:

The current licensee is under revocation pursuant to Section 429. 14( 1)( a)( e) o) Florida Statutes ( F. S.).

During a complaint investigation conducted on April 28, 2015 four deficiencies were cited including two

class I, one class II, and one unclassified; in the areas of Resident Care, Staffing Standards and

Unlicensed Activity.

Therefore, pursuant to Sections 408. 815( 1) ( a)( b)( e), ( 3) Florida Statues your Change of Ownership

application is denied.

EXPLANATION OF RIGHTS

Pursuant to Section 120. 569, F. S., you have the right to request an administrative hearing. In order to

obtain a formal proceeding before the Division of Administrative Hearings under Section 120. 57( 1), F. S.,

your request for an administrative hearing must conform to the requirements in Section 28- 106. 201,

Florida Administrative Code ( F. A. C), and must state the material facts you dispute.

SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS.

If you have any questions or need further assistance, please call Keanna Green at ( 850) 412 - 4419 or e-

mail at Keanna . Green @ahca. myflorida. com.

e-,

Catherine Avery, Manager

Assisted Living Unit

Agency for Health Care Administration

cc: Legal Intake Unit, MS# 3

EXHIBIT 1

THE _

2727 Mahan Drive • MS # 30 ° Face book. com / AHCAFIorida

Tallahassee, FL 323o8 = — ;? Youtube. com / AHCAFIorida

AHCA. MyFlorida. com Twitter. com / AHCA_ FL

SIideShare. net / AHCAFIorida

Edwinola Retirement Community

March 11, 2016

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE: Edwinola Retirement Community

Case Number: 2016002593

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed Notice of Intent to Deem Incomplete and Withdraw from

Further Review of the Agency for Health Care Administration ( AHCA). The title may be Notice of Intent to

Deem Incomplete and Withdraw from Further Review or some other notice of intended action by AHCA.

An Election of R_ ights must be returned by mail or by fax within 21 days of the day you receive the attached

AHCA. Notice of Intent to Deem Incomplete and Withdraw from Further Review or any other proposed action by

If an Election of Rights with your selected option is not received by AHCA within twenty - one ( 21) days from

the proposed date you action received and a final this notice order of will proposed be issued. action, you will have given up your right to contest the Agency' s

Please reply using this Election of Rights form unless you, your attorney or your representative prefer to reply

according to Chapter 120, Florida Statutes ( 2006) and Rule 28, Florida Administrative Code.)

Please return your ELECTION OF RIGHTS to:

Agency for Health Care Administration

Attention: Agency Clerk

2727 Mahan Drive, Mail Stop # 3

Tallahassee, Florida 32308

Phone: ( 850) 412 - 3630 Fax: ( 850) 921 - 0158

PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS•

OPTION ONE ( 1) I admit to the allegations of facts and law contained in the Notice of Intent to Deem

Incomplete and Withdraw from Further Review, or other notice of intended action by AHCA and I waive

my right to object and have a hearing. I understand that by giving up my right to a hearing, a final order will

be issued that adopts the proposed agency action and imposes the proposed penalty, fine or action.

OPTION TWO ( 2} I admit to the allegations of facts contained in the Notice of Intent to Deem

Incomplete and Withdraw from Further Review, or other proposed action by AHCA, but I wish to be

heard at an informal proceeding ( pursuant to Section 120. 57( 2), Florida Statutes) where I may submit

testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that

the fine should be reduced.

OPTION THREE ( 3) I dispute the allegations of fact contained in the Notice of Intent to Deem

Incomplete and Withdraw from Further Review or other proposed action by AHCA, and I request a

formal hearing ( pursuant to Section 120. 57( 1), Florida Statutes) before an Administrative Law Judge appointed

by the Division of Administrative Hearings.

Edwinola Retirement Community

March 11, 2016

Page # 2

PLEASE NOTE: Choosing OPTION THREE ( 3), by itself, is NOT sufficient to obtain a formal hearing.

You also must file a written petition in order to obtain a formal hearing before the Division of Administrative

Hearings under Subsection 120. 57( 1), Florida Statutes. It must be received by the Agency Clerk at the address

above within 21 days of receipt of this proposed administrative action. The request for formal hearing must

conform to the I . requirements of Rule 28- 106. 201, Florida Administrative Code, which requires that it contain:

The known; name and address of each agency affected and each agency' s file or identification number, if

2. Your name, address, and telephone number, and the name, address, and telephone number of your

representative or lawyer, if any;

3. An explanation of how your substantial interests will be affected by the Agency' s proposed

action;

4. A statement of when and how you received notice of the Agency' s proposed action;

5. A statement of all disputed issues of material fact. If there are none, you must state that there are

none;

6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant

7. reversal or modification of the Agency' s proposed action;

A statement of the specific rules or statutes you claim require reversal or modification of the

Agency' s proposed action; and

8. A statement of the relief you are seeking, stating exactly what action you wish the Agency to take

with respect to its proposed action.

Mediation under Section 120. 573, Florida Statutes, may be available in this matter if the Agency agrees.)

License Type: Assisted Living Facility License Number: 7295

Licensee Name: Edwinola Retirement Community

Contact Person:

Name Title

Address:

Street and number City Zip Code

Telephone Nbr.: Fax Nbr.:

Email ( optional )

I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health

Care Administration on behalf of the licensee referred to above.

Signed: Date:

Print Name: Title:

Hoeler, Thomas

From: Smith, Craig H. < craig.="" smith="" @hoganlovells.="" com="">

Sent: Thursday, June 16, 2016 10: 04 AM

To: Hoeler, Thomas

Cc: Selby, David

Subject: GV Dade City, LLC - Edwinola CHOW Application

Tom,

As you requested, I am sending you this email to reiterate and confirm that GV Dade City, LLC withdraws both its CHOW

Application pertaining to The Edwinola assisted living facility and its Petition for Formal Administrative Proceedings

relating to AHCA' s Notice of Intent to Deny that CHOW Application. I appreciate your having Mr. Selby cause DOAH to

relinquish jurisdiction of the pending administrative case regarding that Petition so that AHCA can close that matter

entirely in light of the withdrawal of the CHOW Application.

Thank you, and please contact me if you have any questions or wish to discuss further.

Regards,

Craig

Craig Partner H. Smith

Hogan Lovells US LLP

215 S. Monroe Street

Suite 602

Tallahassee. FL 32301

Direct: 1 850 309 0009

Fax: [phone]

Email: craig. smith@hoganlovells . com

www. hoganlovells. com

Please consider the environment before printing this e - mail

About Hogan Lovells

www. Hogan hoganlovells. Lovells is an com. international legal practice that includes Hogan Lovells US LLP and Hogan Lovells International LLP. For more information, see

CONFIDENTIALITY. This email and any attachments are confidential, except where the email states it can be disclosed; it may also be privileged. If

your received system. in error, please do not disclose the contents to anyone, but notify the sender by return email and delete this email ( and any attachments) from

EXHIBIT 2