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PetitionforFormalAdministrativeHearing-Sample
- 1. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Party 1, ALJ3, Inc, Petitioner, vs. ACHA No. 0000054872 State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION Respondent, ___________________________________________________/ PETITION FOR FORMAL ADMINISTRATIVE HEARING Petitioner, Party 1, by and through their undersigned consultant and pursuant to Sections 120.569 and 120.57(1), Florida Statutes and Rules 28106.201, 28106.2015, Florida Administrative Code, file this petition for formal administrative proceeding and state: 1. The affected agency is The Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. The ACHA No. is 00000548872. 2.Petitioner is Party 1, ALJ3, Inc., 7421 XXXX Court, Jacksonville, Florida 32210. Petitioners are being represented in this proceeding by Tucker Contract Consulting, 5606 Chirping Way West, Jacksonville, Florida 32222; Telephone (904) 4696741; Facsimile (904) XXXXXXX. PETITIONER SUBSTANTIAL INTERESTS ARE AFFECTED 3. AJL3, Inc. was formed and registered with the State of Florida on October 18, 2012, by Party 2, 7530 103rd Street, Suite 8, Jacksonville, Florida. (Exhibit A). Petitioner’s substantial interests are affected by being listed as a last director of ALJ3, Inc. which affects Petitioner’s ability to apply for licensure with the Agency for Health Care Administration in the future.
- 2. 4. On March 7, 2015, the Petitioner received an Administrative Complaint by Certified Mail regarding an administratively dissolved corporation, ALJ3, Inc. On March 24, 2015, Party 1’ consultant responded to the Administrative Complaint by fax and U.S. Express Mail admitting to some of the allegations of facts contained in the Administrative Complaint and requesting an Informal Hearing. On March 27, 2015, Petitioner’s Consultant received Order of Dismissal Without Prejudice To Allow For Amendment and Resubmission of Petition (Exhibit B) advising that respondent’s response was legally insufficient and advising Respondent to file a Petition for Formal Administrative Hearing within fifteen (15) days of rendition of the Order of Dismissal Without Prejudice To Allow For Amendment and Resubmission of Petition. Petitioner is filing this Petition for a Formal Administrative Hearing in accordance with the Order of Dismissal Without Prejudice To Allow For Amendment and Resubmission of Petition. DISPUTED ISSUES OF MATERIAL FACT 5. Petitioner was not the last director or principal of ALJ3, Inc. Petitioner was not aware she was listed as a principal on the incorporation registration with the State of Florida. The Registered Agent on the Divisions of Corporations registration is Party 2. Petitioner was fraudulently listed without her consent or knowledge. Petitioner was not aware that ALJ3, Inc., was not licensed by the Agency for Health Care Administration. Petitioner initially agreed to function as the Facility Administrator under the ownership of Party 2 when Ms. Croker initially approached Petitioner regarding ALJ3, Inc. and worked in that capacity for the duration of the operations of the facility. 6. Ms. Croker approached Petitioner regarding a partnership when she could not qualify for the lease of the facility independently. Ms. Croker advised that she would have her attorney prepare a partnership agreement for both partners to sign to make the partnership
- 3. official. Ms. Croker advised Petitioner that ALJ3, Inc., was licensed by the State of Florida Agency of Health Care Administration and asked Petitioner to procure an Occupational License. Petitioner procured an Occupational License as requested by Ms. Croker (Exhibit C). Petitioner also signed the lease to procure the property but was never presented with the promised partnership agreement after the lease was signed. Therefore, Petitioner continued to operate in the capacity of Facility Administrator under the ownership of Party 2. 7. Ms. Croker presented the following documents to Petitioner: ●AHCA Local Zoning Form for ALJ3, Inc Living and Adult Family Care Homes (Exhibit D) ● Fire Alarm System Record of Completion (Exhibit E) ● Inspection and Testing Form (Exhibit F) ● Fire Safety Inspection (Exhibit G) Exhibit E list Party 2 as the property representative and advise the system operation and maintenance manuals are located with the owner. Exhibit F list Party 2 as the Owner Contact. Exhibit G lists Party 2 as the Owner/Manager and receipt is acknowledged by signature of Party 2 dated May 6, 2013. 8. The facility was abandoned by Ms. Croker on or about May 2014 and Petitioner continued to provide care for the residents of ALJ3, Inc. in a desperate attempt to provide interim care for residents until she could either (1) licence the facility in her name alone or (2) find suitable placements for the residents and close the facility. Party 2 abandoned Petitioner with seven months remaining on the lease, which Petitioner honored independently. Petitioner was not paid after Ms. Croker abandoned the facility and financed the daily living necessities of residents and the monthly rent for the property out of her personal funds. Ms. Croker wanted to start another business and publicly demanded several times that Petitioner
- 4. remove her from the lease. The Lessor would not allow Ms. Croker to be removed from the lease. 9. ALJ3, Inc. received payments for residents from Lutheran Social Services which inclined Petitioner to belief ALJ3, Inc. was licensed by the Agency of Health Care Administration. Petitioner based this belief on her previous experience as owner of licensed facility HH Community Center which was a vendor of Lutheran Social Services. HH Community Center was provided the attached letter after providing licensure proof to become a vendor for Lutheran Social Services (Exhibit H). 10.Petitioner also had consistent communication and interaction with resident(s) case managers which led her to also believe ALJ3, Inc. was licensed by the Agency For Health Care Administration because Chapters 429.08 (d) specifically states “The employer of any person who is under contract with the agency or department, or the Department of Children and Families, and who knowingly refers a person for residency to an unlicensed facility; to a facility the license of which is under denial or has been suspended or revoked;or to a facility that has a moratorium pursuant to part II of chapter 408 shall be fined and required to prepare a corrective action plan designed to prevent such referrals.” Petitioner had a reasonable expectation that if ALJ3, Inc. was not licensed with the Agency For Health Care Administration, that the case managers would not have allowed or referred residents to be placed in the Facility. 11. Petitioner was not notified or aware that ALJ3, Inc. had been administratively dissolved by Florida Department of State, Division of Corporations, on September 27, 2013. 12. Petitioner was made aware that ALJ3, Inc. was not properly licensed by the Agency For Health Care Administration on September 12, 2014, when the Agency surveyor
- 5. advised her that the ALJ3, Inc. was unlicensed during a telephone call. Petitioner did not admit by telephone that the ALJ3, Inc. was operating as an unlicensed facility. 13. Petitioner was never interviewed by Agency surveyor during Agency surveyor’s October 21, 2014 review. Petitioner has never met Agency surveyor on either occasion he/she visited the ALJ3, Inc. STATEMENTS OF ULTIMATE FACTS 14. Party 2 was the only and last director of the ALJ3, Inc. 15. Petitioner never signed a partnership agreement with Party 2 and never became a partner or director of ALJ3, Inc. 16. Party 2 owned and operated ALJ3, Inc. unlicensed in violation of Section 408.812, Florida Statutes. 17. Petitioner facilitated the facility from October 2013 through September 12, 2014 without knowledge that the ALJ3, Inc. was not licensed by The Agency For Health Care Administration. 18. Petitioner had difficulty finding suitable placement for residents after Petitioner received cease and desist notice and Petitioner could not and would not abandon the residents or allow the residents to become homeless without shelter and therefore, Petitioner continued to provide care for residents until October 21, 2014, when adequate placement could be found. RULES AND STATUTES ENTITLING PETITIONER TO RELIEF _ 19. Petitioner is entitled to relief pursuant to Sections 120.569 and 120.57(1), Florida Statute and Chapter 58A5.016, Florida Administrative Code. DEMAND FOR RELIEF WHEREFORE, Petitioner respectfully prays for the following relief:
- 6. A. The Agency for Health Care Administration grants Petitioner’s request for a formal hearing. B. This Petition be forwarded to the Division of Administrative Hearings for assignment to an Administrative Law Judge and, after a formal administrative proceeding, enter a final order dismissing Petitioner, as the last director of the ALJ3, Inc. C.The findings of undisputed facts be accepted as ultimate facts and conclusions of law be consistent with Florida Statutes and Florida Administrative Code as cited in this Petition. D. Petitioner’s fine for operating an unlicensed facility from September 12, 2014 to October 21, 2014 be overturned due to extenuating circumstances. RESPECTFULLY SUBMITTED this 31st day of March, 2015 Tucker Contract Consulting, LLC ______________________________ Yolanda M. Tucker 5606 Chirping Way West Jacksonville, Florida 32222 Telephone (904) 4696741 Facsimile (904) 6727654 CONSULTANT FOR PETITIONER CERTIFICATE OF SERVICE I, HEREBY CERTIFY that a copy of the foregoing Petition for Formal Administrative Proceeding has been furnished by US Mail to Richard J. Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308.
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