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HomeMy WebLinkAboutSubmittal-3FAMILY BOARDING HO CARLOS WILLIARD & FLANAGAN, P.A. Jeffrey M. Flanagan, Esq. 999 Ponce de Leon Boulevard Suite 1000 Coral Gables, Florida 33134 (305) 444-1500 INC. stiootrrED INTO THE !FOC RECORD FOR IAM1212J- ON TABLE OF CONTENTS 1. Photographs 2. Boundary Survey 3. State of Florida & City of Miami Licenses 4. Management Plan 5. Resumes Submitted into the public record in connection vvth item 2Ofl os- Priscilla A. Thompson City Clerk 1024 SW 19 Avenue, Miami, FL 33143 Submitted Into the publi6 record in connection with item `P2• P-2- on -11-L1 -05 Priscilla A. Thompson City Clerk 1026 SW 19 Avenue, Miami, FL 33143 Submi' - • n o e public record in connectio ith item P2 ,- on 4 05 P►iscilla A. Thompson City Clerk 1800 SW 11 Terrace, Miami, Florida 33143 o e public record in connection w'th item Pz• 3?- on a ©S Prisccila A. Thompson City Clerk 1895 SW 11 Terrace, Miami, FL 33143 ubmltted Jntothe public record in connecti n With item TE. on Priscilla A. Thompson City Clerk 1144 SW 19 Avenue, Miami, FL 33143 Submitted into ` e Public h record in connection itas item n .P. Priscilla A. C ty Clerk 2 BOUNDARY SURVEY GENERAL NOTES. II SARIS CF REARM. ASSURED MERIDIAN 21 ELEVATIONS SHOW 4EIEON ARE RELATIVE 70 NATIONNL EMETIC VERTICAL OAILN(ALO.V.O.1 01 LOCATION NO IDENTIFICATION OF WILITIES ON ARLON AOJiCENT TO THE PROPERTY VERE TOT *TUN AS SUCH 1W1HINi714 VAS NO} 4) NOT VALID 11100117 THE SIO/MTU+E A1O THE 01110IMY. SUSS SEA- OF A FLORIDA LICENSED iSAVEYOR AND %APPER- S1 THIS SURVEY IS NOT INTENDED FOR CONSTRZCI1124 PLRPDSEB S1 ENCROACHMENTS MO VZOLATI016 ON SURVEY/ IF AVT7. LEGAL DESCRIPTION LOT 24 IN BLOC! 24.0E AMENDED PLOT OF SHEI:aIaDU THEREOF A7 RECORDED IN PLOT BOCK, P. AT RP+CE 9U. RECORDS OF M1AF11 DMDE COUNIY. FLI)RIOR. LOT 1 BLK 24 SKETCH OF SURVEY SCALE. L' - 20' LESSIAr F A - F1110 01 • CMAETE MONUMENT IR - IRON 1100 IP • IRON PIPE R/Y - RIGHT ON VAT POB - POINT OF 8E01INIiO POC - POINT OF CUIENCETENT PC - POINT OF CURVE POC - POINT ON A CURVE 04NIN LINK FENCE -A-- 101700 PI-Na PO - PLAT 00:K P • PRISE M - NEAQDi09 0 - DEM R - RA0101 A - ARC S - CENTRAL ANIILE C - 01000 X:)t%`- ELEVATION —1-1- NON-VEN1011R KIi311 - CONCETE -U• - OYO1*50 L)IE 0 MO® - CATCN RAS]N L,f THEr N+!FI 1F muun.�T-. on1 Rag r; ^.rn LOT 2 BIJC 24 LOT 23 BLK 24 Submitted Into the thiic record in connection os th item £on Priscilla A. h ymp son CERTIFICATION OF BOINiDR1 54JRVEY. I HEREBY CERTIFY THA1 THIS SURVEY WAS MADE UNDER Mr RESPONSIBLE CHARGE AND TO THE BEST 04 Mr I_NOOLE00E AND BELIEF. THIS SURVEY MEETS 1HE MINIMI!M TECHNICAL 51ANUAR05 AS SET FORTH BI THE BF4ORO OF PR4FE5S10NAL LAND FURY ER 61047 g FLORIDA ADMINISTRATIVE +:ODE 01 +VAN IyT�SF i+1)N 472.927. FOR (DA 1017TES. IULIO S. PITA. P,L.S PROFESSIONAL 1AN0 SORVE'Y0 L H:ENSE N0. P5M 5789 71ATF ffr FLORIDA J.S.P. SURVEYORS. INC. LAND SURVEYORS L6 - 6971 7221 C0RAL WAY. SUITS 121 141AM1. FLCIF11134 33155 a.i01.E. .305 1 262 -204 SECTION. 1 0 - 54 - 4 I ADE CERTIFIED TO FAMILY 90ARO114G HOME. INC. HOWARD L. r:UKER, E50. COMMERCEBANK. N.A.. ITS -_In5CESSORS AND; OR A55tpm5. A71M4 ATTORNEYS TITLE INSURANCE FUND. 1t4[. ,1114,10 25554 187 7417/4`_+ 4478 4! 11 101-4 r0 1411411.11. 77452 DNT£ 6 / 24 / ©2 REF02 . 06 . 49 - C 4253 BOUNDARY SURVEY LOT 8 BLK 1 LOT 30 BLK 1 LOT 9 BLK 1 5 1 STORY S • 11 CBS :0 5.50 . Wt. Syr 5.0 5045. LOT 10 BLK 1 FNO ts2' tP NO 10 eaa Submitted Into the pi. record in connection item PZ. yr on _ Priscilla A. Thom Cityl LOT 28 BLK 1 A 4,2' IP N0 f0 meow- irate, I) BASIS ff SEARING. ASOMEO MERIDIAN 2) ELEVATIONS MOWN MEIELM NE RELATIVE TO NATIONAL OEWETtC VERTICAL OATOHN.O.V.0.1 3/ Lecovrtem NO IDENTIFICATION O, UTILITIES OP NR/01 N).Y,CENT TO 7PE PROPERTY VOW NOT BECOME AS SUCH INFENHATIIN VM NOT RE0ESTEO. 41 NOT VALID VERMIN THE TI01MTUM ANO THE 01I0INAL NOSED SEAL Cr A FLORIDA LIB SURVEYOR A10 MAPPER. 01 THIS OURVEP IS NOT IRTE)ICO FOR COIOOS)CTIOI PURPOSES S1 EICAOAOSOTS N0. O V1ATIOMS M SRVSWIF ANT). SY 19 AVENUE 120.0' PAVEMENT) — — 50.0' TOTAL SKETCH OF SURVEY SCALE. 1• - 20' GAO • MONO CM • COMCAEIE MOMENT IA - IRON ACO I► - t001 PIPE AAV - R10T OF VAT POR • POINT OF SMSI)NIMO POC - POINT O' CO AIBRO TENT PC- POINT 0'CURVE AOC - POINT 01 A CURVE -• --- CHAIN LINK FENCE ••."--- YOCO MINE RI • PLAT SOOT P - PAGE A - l*1* 0-DEED A - R CIU0 A • MC ♦ - CENTOV. ANO.E C • CHOW LXX ELEVATION -t--I- NOt-VOUOLM ACFJS L. - CONCHeTE -U- • worm) LIIL jC�l-- IPMRAA CATCH 9.SIM 1L/ t Mt LEGAL DESCRIPTION LOT 29 IN BLOCK I,OF SWANNAIJD2. ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOCK 9. AT PACE 40. OF THE PIIBLU- RECORDS OF MIAMI DADE COUNTY. FLORIDA. Cm4em'Y NLMeEN 1: owal 1 zu rn ItOATE rww «0E. 2004 5• FA. A 4+SE 55.5 arvAIKM ' .— TA FNO I/2. IP Eta COP CERTIFICATION OF BOUNDR0 SURVEY. I HEREBY CERTIFY THAT THIS SURVEY WAS MADE UNDER MY RESPONSIBLE CHARGE AND TO THE BEST DM MY KNOWLEDGE AND BELIEF; THIS SURVEY MEETS THE MINIMUM TECHNICAL STANDARDS AS SET FORTH BT THE BOARD OF PROFESSIONAL LAND 51' :TORS CHAPTER 61017.E FLORIDA ADMINISTRATIVE CODE - R5 •N TO EG TION 472.927. FLORIDA STATUTES. JUL1O 5, PITA. P.L.S. PROFESSIONAL LAND SURVEYOR LICENSE N0. PSM 5789 STATE OF FLORIDA J.S.P. SURVEYORS, INC. LAND SURVEYORS Le - 6971 7821 CORAL MAY. SUITE 121 MIAMI. FLORIDA 33155 PHOI/E. t 30!3 1 262-2404 blic" with os- ?son Clerk 5ECT10N' 1 0 . 54 - 4 1 OUNTY: DADE CERTIFIED T F AMtLT BOARDING -TOME, INC. HOWARD L. KOKER. E50. COMMEPCEBANK. N.A.. ITS SLCCE550R5 AND/CR ASSIGNS, ANIMA ATTORNEYS TITLE INSURANCE =UNO. INC. 120650 El 7/17/95 1144 SW 19 AVENUE MIAMI,FL 73I43 DATE. 6/21 /02 E 02-06-49-E L4253 1 BOUNDARY SURVEY goefw. VOIR CF SEARING. ASSUMED ?EAMON 21 EIEVATICNE SHINN HEREON APE RELATIVE TO NATIONN. GEODETIC VERTICAL 041111iN.G.V.O. / 3) LOCATION NV ICENTIFICATICW OF UTILITIES MOAN ACJACevT TO TTE AISPERTY SERE NOT SEtuRE AS SUER INFOSNATION WAS NOT RECLESTEO. 41 tATT VIEJO WITHOUT THE SIGNATURE RN3 THE oRIOINAL RAISED SEAL OF A FLORIDA LICEMED SURVEYOR ANS MAPPER. DI TWO eLRVEY ID NOT INTEROED FOR OENSTRICTION KRAMER Et ENCROACMENTs ANTI vULATIotis at4 RIJRVETSIF AKYI‘ ° 1 STORY • 1800 CBS 1 STORY RES • 1800 CBS 57.0' syr 4 — wr Submitted Into the public record in connection witil item P2 • on • Priscilla A. ThomPsan City Cle k me 1,23. 54 111 CI_ SY 11 TERRACE (24.0' PAVEMENT) - 50.0' TOTAL SKETCH OF SURVEY SCALE. 1' - 20' Lenec. FRO - FOUND CA - trOCRETE MONLNENT IREIN Ron IP - incie pipE 14/4 - Marti OF vAT POO - POINT OF BEGINNING ACC - Mier GE COMENCEpENT PC - Pole/ OK MAW PEC - POINT PT A CLAW WAIN LINK #0*2 —,--- WOO P.e.Aut pe - PLAY KM P • MOE X • REARMED 2-04104 R RA0111 A - A - CORRAL ANGLE C - MHO X. XX ELEYATICII NON-VENtotLEA ACCESS LINE • IXISCRETE -u- • wEINE04 LIFE 0 - **4443-E IN CR - Graf 11ASO4 LEGAL DESCRIPTION CIJT 12 IN eLC[C1 4.61S6VED 13,07 OF .--4EW,M7Ji441Hk ;; 1,4 Pr ryi THEREOF RR RECrOCED IN PLAT BOO!, e. 4,T q0. Or Tiir f. REc4e0:5 OF 7.11,:411 DAUE COLflTy. C01,44,1111. , 0.4,4 1141, rtry•two [.LPilliCalION 07 KONDRY 54RVE1, HEREBY LERT;Ft THAT THIS SURVEY 9313 MADE UNGER Mf 41.4130E ANO TO THE BEST Or MY KNOWLEDGE Am° 11E61E6, To[s SoRvEl 0EE76 THE MINimOM TECHNICAL STANDARDS RS SET FORTH BY THE BOARD 341 48OFE534113NAL JRSIJAN E,rION 472,027. FLOP104 STATuTES. LANDrIORS .H.PTER 67677.6 FLORIDA AOMINI8mArtvE LODE 1.6410 E. RiTA, P.L.S. PROFESSIONAL LAND SURVEYOR LICENSE NO. P514 5789 411414 06 F10011'6 J . S P . SURVEYORS INC. LAND SURVEYORS 4)4 - 7421 CDR._ WAY. StdITE 121 MIAMI. FLORIO., 33155 pHore. 43415, 262,2404 SECTION I1.41 - 545- 4 I COONTY• oc.DE CERIIPIED TO FrAMILY 904R4IN0 HOME. INC. HOwORO L. Kuk;Ee. Eel). Coo-leEH. N,p.. [45 SUCCESSORS ANC/OR ASSMIJS. 131i44 ATT013NE43 TITLE INSURANCE FUND. INC. t 20650. 1 87 7/17/1,5 IROO 414 II TERRACE M1,1M1.FL 311143 GATE G/2 k7:1 2 REF 02 06 - - P 2ijIDWC41L323 BOUNDARY SURVEY LOT 14 BLK 1 LOT 24 BLK 1 LOT 15 BLK 1 cn M 15.28 2 STORY RES • 1024 CBS IP/ 6./O. B' 0 Cl 6' CI T LOT 16 BLK 1 Submitted Into the public record in connection with item Pt - sy on A • -0r Priscilla A. Thompson City Clerk LOT 22 BLK MICA& MOTES. 11 DABI5 OF MERINO. M00ME0 MERIDIAN 21 ELEVATIONS SNOW HEREON NE RELATIVE TD 1NTIONN- OEDOETIC VERTSCN. DATINUN.O.Y.D.I 31 LOCATSON AND IDENTIFICATION OF UTILITIES ON ANYn ADJACENT ID THE INICIPOITY NE1E NET TERME AR !Ot INFORMATION YAW KIT nrouernm 4) NOT VALID WITHOUT NE 0)ONRIE PAC THE 0RT51NN. MAMBO /EA. IF A FLENI04 LICENSED EIAVEYMR AND MAPPER. 5) THIS PURVEY IS NOT 114Icrt*-0 FOR CO0EDRUCTI01 PIAPOSEO SI ElCADAG4ENTE AND VIOLATION ON 03.01)EY)IF ANY). 9 AVENUE (24.0' PAVEMENT)----- -- — 50.0' TOTAL SKETCH OF SURVEY SCALE. 1' 20' FrO - FOND OI - COCCEIE MOS1ONT IT IRON ROO IP - I00N PIPE 0VV - RIOHT OF YNY P® - POINT OF SEOIMIIMO POC - POINT OF mS0123E T PC - POINT OF CHIVE POC - POINT OI A GAVE --- CHAIN LINif FENCE -- V000 FENCE PR ^ RAT TOOK P - PACE M- MEMAM® 0-OEM 0-RADIUS A - ARC A - CNTRAL MOLE C.0 x- ELEVATION —t—)- VON-VE)IOLM NSF! LINE - =CRETE -V- • R00SEM LINE 0� ' ~nixAT �IB - COi d1IN V - TPIz LEGAL DESCRIPTION LOT 23 IN BLOCK 1.0F SMANNANOA. ACCORDING TO THE PLAT THEREOF AS RECORDED 1N PLAT BOON 9. AT PAGE 40. OF THE PUBLIC. RECORDS OF MIAMI DADE COUNTY. FLORIDA, COMMUNITY 1: 44EL MMKP IL BAKE W Mt. ItAXx 5: Fa4 tart 8. BASE .1000 t56.55' m FNO v2- 1P BLK C▪ OB CERTIFICATION OF 60UNDRY SURVEY. I HEREBY CERTIFY THAT THIS SURVEY VAS MADE UNDER MY RESPONSIBLE CHARGE AND TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS SURVEY MEETS THE MINIMUM TECHNICAL STANDARDS AS SET FORTH BY --THE 60AR0 OF PROFESSIONAL LAND SUR Y0R5 CHAPTER-61017.6 FLORIDA ADMINISTRATIVE. CODE P St NT ECTION 472.027. FLORIDA STATUTES. JULIO S, 001TA PROFE55IONAL LAND SURVEYOR LICENSE N0. PSM 5789 5TATE RF FLOP mg J.S.F. SURVEYORS. INC. LAND SURVEYORS LB 6971 7921 CORAL 'MAY. SUITE 121 MIAMI. FLOBIOA 33155 PHONE. t325) 262-2404 SECTION, I 0 - 54 - 4 1 TY ADE CERTIFIED TO, FAMILY BOARDING HOME. INC. HOWARD L. KUKER. ESD. CDMMERCEBANK. N.A,. fT5 SUCCESSORS ANO/0R ASSIGNS. ATI4A ATTORNEYS TITLE INSURANCE FUNO. INC. 120E50 EI7 7/17/A5 N/A 102,1 54, 19 AVENUE M1AMI.FL 33143 DATE G/21/02 1 AC, 02-0G-49-0 OYc GI-4263 BOUNDARY SURVEY LOT 12 BLK 1 LOT 13 BLK 1 LOT 14 BLK 1 q_sw 19 AVENUE 124.0' PAVEPENT I — — 50.0' TOTAL SKETCH OF SURVEY SCALE. 1' - 20' 11 HMIS IF BEARDEN MMUNIED 1E31IDIAN 21 ELEVATIW9 SHOWN HEREON ARE RELATIVE TO RATIONAL 8EODETTC VERTICAL 64TU4I14.0.V.D.1 91 LOCATION APO IOENIIFICATIOI OP UIILITTE3 ON NOJOR 1E.VYCENT TO TIE PROPERTY VE1E POT ALINE M SU01 IRA pYMTIO1 WAN NOT REQUESTED. 41 NOT VALID WITHOUT THE SIOATOE NO THE ORIGINAL MISm SEAL OF A F1.D0I12A LICENSED MMVEVOR AND POPPER. 51 THIS MAVEN 18 NM INTE?OED FOR COl8TMETIOH PURPOSES 81 FNCNONZHNENTS APO PM:RATIONS CM SLR46T1IF N1Y1. lam FIC - FOUND CH • COVCPETE WYLLENT IN . IROI ROO IP - IRM PIPE IVY - RIONT OF VW PDR - POINT OF BEDIPNINO POC - POINT OF COSENCEPEIIT PC - POINT fF CURVE PCC - POINT CM A COME -�-- 081IN LINK PENCE -e-- WOO FENCE P9 - PLAT TOOK P - PAGE N • 1EAMLNm O - OEM 8-MOWS A - ARC A • CENTRAL MOLE C - CHON[7 x-NX ELEVATION -1—I- Mil-VENICILAII CCM LIPS - CONCRETE -33- OYR.EAO LiNI 0 - E ® - CAT04 BIS11.1 LEGAL DESCRIPTION LOTS 24 b LC IN BLOCK I.DF SWANW.P104. ACCORDING 70 THE FLAT THEREOF 45 RECORDED IN PLAT BOOK R. AT PAGE 49. OF THE PUBLIC RECORDS OF MIAMI DADE COUNTY. FLORIDA. 000 LOT 15 BLK 1 Sub Into record in cne tor► with item P! . on : ° f Priscilla A. Th rnps Clerk Cit., LOT 23 BLK 1 EA FRO I/2. IP 4) BLK COR CERTIFICATION OF BOUNORY SURVEY, I HEREBY CERTIFY THAT THIS SURVEY WAS MADE UNDER MY RESPONSIBLE CHARGE AND TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS SURVEY MEETS THE MINIMUM TECHNICAL STANDARDS AS SET FORTH BY THE BOARD OF PROFESSIONAL LAND SURV PTER S1017.8 FLORIDA ADMINISTRATIVE CODE P UAN 5 T(2N 472.021. FLORIDA STATUTES. JULIO S. PITA. P.L.S. PROFESSIONAL LAND SURVEYOR LICENSE N0. P5M 5784. STATE OF FLORIDA J.S.P. SURVEYORS. INC. LAND SURVEYORS LB - 6971 782I CORA, WA, SUITE 121 M iAM7. FLORIOA 33155 PHONE_. ,305, 262-2404 163TroN 10-54-41 J COUNTY: DQDE CERTIFIED TO FAMILY 50ABONG HOME, INC. HOWARD L. KUKER. E50. COMMERCEBANK, N.A.. ITS SUCCESSORS AND/OR ASSIGNS. ATIMA ATTORNEYS TITLE INSURANCE CURD. INC. 20650 7/9 X N/A AvEHIUE MIAL 3.14 ❑ATE: 0/21 /02 REF: 02-06-49-0 o.c•OL4263 t ,0\ 114(lit.%/1111/1111i:n41/11:; I i / • CERTIFICATE #: 14310 L&. re I.16\ 111111,..%.:11 1'11; .*:ii1111'11,1., State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE LICENSE #: AL5437 ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: CORNER HOUSE 1895 S.W. 11TH TERRACE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 16 Optional State Supplementation Residents: 15 Private Pay Residents: j.. EFFECTIVE DATE: 05/10/2003 EXPIRATION DATE: 05/09/2005 Deputy Secrtary, Division of Health Quality Assurance )41 4,11' 11338 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY (with LIMITED MENTAL HEALTH, LIMITED NURSING SERVICES) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: CORNER HOUSE 1895 S.W. 11TH TERRACE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 16 Optional State Supplementation Residents: 15 Private Pay Residents: 1 CERTIFICAlh #: 7171 LICENSE #: AL5437 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD This is to confiini that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: CDcD 3 0 CT c CORNER HOUSE a. 3. 1895 S.W. 11TH TERRACE MIAMI, FL 33135 ' 8 DADE COUNTY 0 en •••• TOTAL CAPACITY: 16 o Optional State Supplementation Residents: 15 3 Private Pay Residents: 1 0-0 0 la v. 51k- ° EFFEC11VE DA FE: 05/10/1999 EXPIRATION DATE: 05/09/2001 Deputy Director, Div&sio of M aged Care and Health Quality 111H 0441 . i•q 4,4 rt-.f I ir .. 11k h 41i 1Ati State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY (with LIMITED MENTAL HEALTH, LIMITED NURSING SERVICES) This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: cn CORNER HOUSE 1895 S.W. 11TH TERRACE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 16 Optional State Supplementation Residents: 15 Private Pay Residents: 1 Deputy Director, Di'&sion of M aged CERTIFICATE 2685 LICENSZ AL5437 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTII QUALITY ASSURANCE ASSISTIA.,D LIVING FACILITY STANDARD This is to confirm that FAMILY BOARDING HM INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: CORNER HOUSE 1895 S.W. 11T1-1 TERRACE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 16 Optional State Supplementation Residents: Private Pay Residents: 5 EFFECTIVE DA FE,: 05/10/1997 EXPIRATION DA I E: 05/09/1999 Dir, or, Division of Hcalth Qui1ity Assurance I I I License 00051137 Number: Control 1"/ 2036' Number: CAPACITY: STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION crpiith..? &dc,pts'd t as 11, (2.1" Adult Congri,gats, Living CORNER HOUSE 1895 S,U. ilTH TERRACE 05/13/95 Submitted Into the public record in connection with item on Priscilla A. Thompson City Clerk Director ' Division of Health Quality Assurance JEB BUSH, GOVERNOR May 18, 2003 Sofia Carratala, Administrator Corner House 1895 SW 11th Terrace Miami, F133135 Dear Ms. Carratala: RHONDA M. MEDOWS, MD, FAAFP, SECRETARY This letter confirms the findings of the Revisit Survey of your Assisted Living Facility (ALF), conducted on 03/18/03, by Lauren Wescott, Registered Nurse Specialist, representing this office. The resident census on the date of survey was fourteen (14) residents. It was noted all of the deficiencies reviewed were corrected by the date mandated. This letter may be used as summary of this review and is to be attached to any previously provided Statement of Deficiencies. These documents are required to be prominently posted in the facility accessible to all residents and the public. A recommendation for Standard license with Limited Mental Health has been submitted to the Office of Licensure and Certification for the capacity of sixteen (16). This license, when approved, will be forwarded to you under separate cover. Documents relating to State Licensure will be made available for public disclosure, as required by law. If you have any questions, please contact Ms. Wescott or Rachel Sigel, ALF Supervisor, at 305-499-2165. Sincerely, Diane Lopez- Castillo MS, ARNP Field Office Manager Cc. LTCOC/ALF UNIT Submitted Into the public record in connection with item fl »Ofl 24L1.1.gs Priscilla A. Thompson City Clerk Please send all your correspondence to the Miami Address located at the bottom right hand corner of this letter. Headquarters 2727 Mahan Drive Tallahassee, FL 32308 www.fdhc.state.fl.us Area Office 11 8355 NW 53'd Street Miami, FL 33166 State Form: Revisit Report 1) Provider / Supplier / CLLk / Identification Number 11910901 (Y2) Multiple Construction A. Building B. Wing Submitted Into the public3/18/2003 record in connection with itcti p z_ a4-1- on sl t aAi t o v- Priscilla A. Thompson (s NCI Rr&isit 3/18/2003 of Facility ORNER HOUSE Street Address, City, State, Zip Code 1895 SW 11TH TERRACE MIAMI, FL 33135 cpon is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be illy identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each quiremcnt on the survey report form). i'a) Item 005) Date (Y4) Item (Y5) Date (1.4) Item (Y5) Date Correction Completed ID Prefix A1I0S 3/18/2003 Reg. >' LSC ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. LSC Correction Completed Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix — Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Pre fix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. LSC Correction Completed ID Pre fix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed viewed By Reviewed By Date: ignature of Surveyor: �l ,U U Date: —Agencyt iewed By Reviewed By Date: Signature of Surveyor: 0- /(3.3 Followup to Survey Completed on: 2/17/2003 Check for any Uncorrected Deficiencies. Wa.s ■ Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO • FORM: REVISIT REPORT (5/99) u�r1r! au,cu '1) Provider / Supplier / CLLA / Identification Number 11910901 State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Submitted Into the public Is/zoo3 record in connection w�•th 3/item 2 Sz err ��1„�. Priscilla A, Thompson ( "tyntievis,t 3/18/2003 to of Facility 2NER HOUSE Street Address, City, State, Zip Code 1895 SW 11TH TERRACE MIAMI, FL 33135 report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Fach deficiency should be identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each ra.ment on the survey report Form). ) _...Item (Y5) Date (1'4) Item (1'5) Date (''4) Item (Y5) Date Correction Completed prefix L0200 3/18/2003 Correction Completed ID Prefix Correction Completed ID Prefix (eg. 0 Reg. # Reg. # LSC LSC LSC Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix teg. # Reg. # Reg. # LSC LSC LSC Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix Reg. 0 Reg. # Reg. # LSC LSC LSC Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix ^Reg. # Reg. # Reg. # LSC LSC LSC Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix rReg. # Reg. # Reg. # LSC LSC LSC iewed By Reviewed By Date: Signature of Su eyor Date: .gency ewed By —:O Reviewed By Date: Signature ofSurveyor:f�� Followup to Survey Completed on: 2/17/2003 r Check for any Uncorrected Deficiencies. Wu a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO FORM: REVISIT REPORT (5/99) DCC 1 051 7/S6 tif I cif gliiititti POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE, SECT101\;I, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 410-1570 LICENSE YEAR OCT. 1, 2004 THRU SEPT. 30, 2005 LICENSE FOR EAtijj Y jUlARD ING HOME INC ACCOUNTNO, 327066-00115463 LICENSENO, 057160-0001 ISSUED OCT O8 NAME OF BUSINESS FAMILY BOARDING HOME LOCATION 1095 SW 11 TER TO 10 TOTAL FEE PAID FAMILY BOARDING HOME CORNER HOUSE 1026 SW 1V AV THIS IS NOT A BILL: DO NOTPAY . , This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does II exempt the licensee Itortt any other license or permits Mel may he required by 01W.., ' • This license does'nol constitute a certification thel ''' • the licensee is qualified to engage In the business, profession or occupalion specified hereon. The license Indicates payment of the occupational • license lax only. $ 40. ()0 • THIS IS NOT A BILL DO NOT PAY This ,S1tE111C11 of an occupational licen.se (fowl not permit Ilia licensee to vi)lale any zoning laws of the city nor does it exempt the licensee nom any other license or permits Inal may be required by law. This license does not Constitute a cerligcalion that the licensee is quelified lo engage In the busineSS. ,pinfession or occupallon specified harnon. \the license lndicales payment of Me occupational ,ense lax only. $40.00 ()CC trOfrt 1,96 POST TIIIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2003 THRU SEPT. 30, 2004 LICENSE FOR F AM I LY• BOARD-ING-HOME--INC ACCOUNT NO: 327866--00118463 LICENSE NO. 097160_0001 ISSUED NAME OF BUSINESS FAMILY BOARDING LOCATION 1895 SW 11 TER IS HEREBY LICENSED TO ENGAGE IN OR MANAGE :THE OPERATION OF: ••' BOARDINGHOUSES O C-T 1-11 HOME TN _2003 TOTAL FEE PAID FAMILY BOARDING HOME TO /0. CORNER HOUSE 1926 SW 19 AV MIAMI FL 33135-5129 4 ACCOUNT NO, 3 2 7 B 6 t! — 0 LICENSE No. 0 9 7.1 6 [1— 0 NAMEOFnusirET' FAMI LQCATION .I. O 9 5 S 111I ; I_ICl"F,SL IN ,; CONSPICUOUS PLACE No l rI iANSrrHAItl 1_ ill VAI_II) AT ANOTHE N At Ll IESS UNLCiSG!1PI'FI11V1:1) HY rIIL I.ICENSL SCCTION, CITY or Mlnr.tl.'r.o Po>: .1:10700 MIAA1r, FL :132:13-o7u0 f'I IONL (205) 4I6-11,iu LICENSE 118463 01. ;�uro OCT 1 8. 2002 rorAL l'EF PAIL) Y BOARDING HOME INC TER LICENSE YEAH OCI. 1, 2002 THRU SEPT,30, 2003 17F AMI L`Y BOARDING' HOMC INC_ THIS IS NOT A B DO NOT PAY This issuance of an occupational IiylenSe,r�0e5 pet .d the licensee to violate any zor)in91a tat), nor (loos it eKempt. the liceo ea TTOiTt, I,cmm� pr pnm(iiB that may 60 falultad.by I his II[ensu dpe9 nol'COrytliluie 4 C• '• Ir}•ii the Iicensee Is qualiGEf110.Crgage 11i';Gl(!, oh. • p �sion rx c,r:cupatidn apecthed'tiB!eonri,'; The license indn:ates pa (met; tt(Iho cry�Cups S4/� Ur laa only. 'Ii a Q U lJi, M:,. THIS IS NOT =A' DO NOT PAY This issuance of an occupational license does not permll the Ilcensee 10 violate any zoning laws of the city nor does 11 exempt the licensee tram any other.' license or pefmlls That may be required by law, • This license does not constitute a certification that the licensee Is qualified to engage In the business,',:: prolesslon or occupation specified hereon. The license Indicates payment of the occupational $ 4 0 . CJO" lax onty. ACCOUNT NO. LICENSE NO. NAME OF BUSI • LOCATION 11 le, r. citt of4fliiarn POST THIS LICENSE.IN A CONSPICUOUS PLACE'' NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2001 THRU SEPT. 30, 2002 LICENSE FOR FAMILY BOARDING HOME INC 327866-001 /8463 097160'-0001 ISSUED OCT t2, 2001 EaS FAF1AMILY rBOARDING HOML INCER IS HEREBY LICENSED TO ' ENGAGE.IN OR MANAGE fr,THE OPERATION OF: BOARDINGHOUSES TOTAL FEE PAID FAMILY BOARDING HOME COR 'TO 1026ER SW 19SE AV MIAMI FL 331.35-5129 • I ' DGCO17/9 LT of Alia : — . POST THIS 'LICENSE IN -A CONSPICUODS'PLACEf,, NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS: UNLESS APPROVED BY THE LICENSE SECTION, CITY-. t. OF MIAMI. ,P.O. BOX 330708, MIAMI, EU,33233-0708 PHONE (305):418-1570 • , ct LICENSE YEAR OCT. 1, 2000 THRU SEPT. 3q, 2001 LICENSEACOR EAM1LY ROA R n ts4r.HflM4 INC ACCOUNT NO. 3 2 78 66-001 1 84631 LICENSE NO. 097160-0001 ISSUED NAME OF BUSINESS FAMILY BOARD LOCATION 1895 SU 11 TER • FRY LICENSED , 411-, NAGE, • •i IN • ENCIA—(-4 OR MA1ThEOEAT.toN OF. sEs . t3OAR4t • • "Ir rt, HISIS;NOT:A:B DO NOT PAY' This Issuance of an occupallonal license does not permit the licensee to violate any zoning Iasi of the:''''.'?-''' city nor does II exempt the licensee from any other 4',...,:•1 license or permits Ihet may be required trYlaw. . •••• This!license does not chnstilyis a certlkation the lidelisee is qualified tO engage in Ibe profession or occupation specified heiot The license Indicates paymentplihe rational lobse tax only., r :„ 1 '" .•'''')1','Y • TOTAL *PAID r ;FAMILY SPAR OL NG HOME CORNER ki r'yO 14 • I ' vole}�A....:i++t.-�k3 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor [Ices it exempt the Iicen.ee Irom any olher license or pr_rmils Mal may be required by law. This licenso does not conslilure a certilicnlion Ihal the licensee is qualified to engage in the business. pmfeselnn or occupation specified hereon. The license indicales payment of the occupational 4 0' ocppse lax only. • ()CC it 051 7t96 tzttrt POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1999 THRU SEPT. 30, 2000 LICENSE FOR F A M [ LY R0kRiLLAC j1M_�' j1yL ACCOUNT NO. 32 7366-001 1 846 3 LICENSE NO. 097160-0001 ISSUED D[-r (1L., 99 TOTAL FEE PAID NAME OF BUSINESS FAMILY BOARDING HOME INC LOCATION 1395 SU 11 rER TO IS HEREE3.Y LICENSED TO .: ENGAGE IN'OR MANAGE.., .THE OPERATION OF-' FAMILY HOARDING HOME CORNER HOUSE 1026 SU, 19 AV •M[A1.1[ F!. 331.3 w 'UGC .051 7.,90 i n POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION. CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1998 THRU SEPT. 30, 1999 LICENSE FOR L Y Ft ACCOUNT NO. 327866-00118463 LICENSE NO. 097160-0001 ISSUED 0 C_T f;_2_)998 TOIAL FEE PAID NAME OF BUSINESS FAMILY EIOARDING HOME INC LOCATION 1695 SW 11 TER IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE'OPERATION OF: BOARDINGHOUSES a) TO )0. FAMILY EOARDING HOME COkNEk HOUSE 1026 SW 19 AV L MIAMI FL 33135-5129 THIS IS NOT A BILL DO NOT PAY $40. Thls issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does 11 exempt the lIcem.,ee from any other license or permits that may be required by law. Thls license does nol constitute a certification that the licensee is qualified lo engage In the business. profession or occupation specified hereon. The license Irk1ICE1161 payment of the occupational tiense IBA ority. (Cit1 of Aiami CERTIFICATE OF USE FERE SAECTIE Pf-RtlE1 FAMILY BOARDING HOME 1°26.Sw 19 AV MIAMI FL 33155-S129 r DATE ISSUED: j 2 2 :) o II, .1 k i kr. ‘1,1111W:111, NL111 11011!;11.1.'ililt,. 11 •1 'dt111111.,1111!,1111;t1C, (If 1:161111.1k! 1111:Yi d 111:W lirlISI In! I /1111111c] iI II'1 :;.W. AVi,11114!, dill I ',MI, IIl; I P.19 VALID FROM: 31/017 ; T01 7 3 1 / 0 3 ACCOUNT NO: 3 2 7 - 1 3 SERVICE ADDRESS: 1 ft 9 5 SW 11 14.2 APPROVED USE: . • CU15-C.3..R.F. NON -PROF I - RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCAL ION Ai ot:i.(1i.,^McV P.H1)1:1,.;! • FAVOR DE Maf; TM!? ES'ILE. CUT: rincit no siito .11,111.1't 1-1i,1-1 1-; 1,1,f, ;(-1, DOC NO65 (6/97) (I) a) (Do c 3 o cr uN, Tit o-f CERTIFICATE OF USE F IRE SAFETY PERMIT FAMILY HOARDING HOME 1026 Su 19 AV miAmr FL 31135—;129 I 111.. ,•11111,:.11, J, ti I kilt .111,11,1,, II .1,11 11 lri, `.; VI. .'1111 1:iil'o)1111 i•i•I DATE ISSUED: 2/ ? VALID FROM: Di / /:-.) TO:1 si 102 ACCOUNT NO: -••,27,-:;6 6- 1 5 SERVICE ADDRESS: 1895 SW 11 Tr APPROVED USE: C U 1 5 - C - F. NON -PROF RESTRICTIONS: • PLEASE DISPLAY THIS CERT ITICAT IN A CONsPICUORS LOCATioN Ai A.( in icy Ai • FAVOR DE 11,10STRARE!;TFCri1 fIFICADO EN IIN VISIM t FN I ,N 1,F! :f01;!!, \Ifryt,A$4.79,04," - C DOC N065 (8/97) n •0 o - o Tit of Aliarni CERTIFICATE OF USE FI SAFLTY PFP.N!IT FAMILY JOAkDING HOMr: 10?5 SW ';') AV MIAMI FL 3'i3";—Y:19 Nor, IIi! 116111. CI onge corpfirolo nms1 1111 ol,L11,11.,(1 411 1)(18)1111r) 1101 /(olio() :11 ;18I I 10(8, I '11(88: 11(1.-1) II';;1 190 DATE ISSUED: -; / • VALID FROM: . . TO:. : / .1) : ACCOUNT NO: 7o— SERVICE ADDRESS: ?95 SW TLR APPROVED USE: (.4 NI,L)N—P:OF IT — C.U. RESTRICTIONS: • PLEASE DISPLAY TFIIS CERTIFICATE IN A CONSPICUOUS LOCATION Al • FAVOR 01: MOSTRA11 I-STE cHITII ICA00 1- 1,1 1114 !;11-10 W:1111 r 1,1'11 A 111)11 r-i.'1C)14 II) . . fts DOC N065 (8/97) Tit af JIWt CERTIFICATE OF USE crop qAcFTN, PrOMTT 1AMTI VRnA gni PUG i•AnNiF c w 1 Q AV MT APAT FI lA1ls-S1?(7 47; ! ! !! I.; Nan- 111 Of 1.11,1ogi;IIIQ lypi: 1 1111 dir i(1.1 !“ 1111,1,1,11,1 /Hi :'rif .1011 I,;,r l'11,11t• i l'el DATE ISSUED: R7/ns/nn VALID FROM: T ni /ni inn al7 / 1 inn ACCOUNT NO: 7 17Sfl SERVICE ADDRESS: 1RQS Su 11 TFP APPROVED USE: rii1S-1,a_P.-F_ NrIN-DPnP T r _11_ RESTRICTIONS: • PLEASE DISPLAY THIS CLFII iricA IL fi A CONSPICUOUS LOCAI ioN Al rinciipAr •;.; • FA VD!? DE A10.511110: 17:: C171111rICADO I:N I IN !:1114 I I. TJ II 1,11 ir ! Cui.11 DOC NO65 (8/97) (Cti of Airarti CERTIFICATE OF USE FIRE SAFETY PERMIT HOME MIAMI FL 33135-5129 • PLEASE DISPLAY TIIIS CERTIFICATE Iti A cormPicuoir; orATIoN Al 01:Cul •Avit:',' AO( • FAVOR DE 11.10.5-11-1/1111."[;11- 1(.711,0 fl 111) .n vii 1 r d I ; I • DATE DATE ISSUED: VALID FROM! ACCOUNT NO: ;1, ; r1, tit 11,11.,1t,t.t1,1t1. 11 •.1., IA1,111 ill 1,11,111111; 111, 1`11,o. I 111{11 .11, Mr.! • 11131.011, 111, t ,111. 03/06/99 01/01/99 Ta12/31/99 327866- 182350 SERVICE ADDRESS: 1895 SW 11 TER APPROVED USE: CU15-C.B.R.F. NON-PROFIT - C.U. RESTRICTIONS: n.. r . DOC i0G5 (8/97) (: it of cffliami CERTIFICATE OF USE FIRE SAFETY PERMIT FAMILY dUARDINL HUME 1026 SW 19 AV MIAMI FL 33135-5129 • . , DATE ISSUED: L/2 I0 1 I 9 VALID FROM: olioi /9e • ,*orlilicZilo Non I lowilt,iii1)1.t.11 • ,„,11 111..t Ini..,;rie:;S. Of cli:ingo 1,11•41.• 11,11%0 1111 rd I)(! 11111:11111,1 1,1111 I :1!Ilt III /A)111f1(1 ill .1 1.1 ;IVIN II It., .101 l 1.1111, 11,010 _)I I, i ttti To:12/31/98 ACCOUNT NO: 327,366— 182350 SERVICE ADDRESS: 1?,95 SW 11 TER APPROVED USE: cuis—c.e.R.F. NON—PROFIt — C.U. RESTRICTIONS: • PLEASE DISPLAY THIS CEFITIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY AIJIMF11 • FAVOR DE MOSTRA11 ESTE cEnTIFICADO EN UN sal° vunLE EN LA DWECCONiriri, comvi !chi DOC #065 (8/97) wr/ cuu* OCCUPATIONAL LICENSE TAX 2005 rmsr-:Lxsa , TAX COLLECTORmmM/'oAosCOUNTY ' STATE orFLORIDA U.S.sruss �� 140 W. ��" �xpm�sosr� coos pmo 14th FLOOR uor p BUSINESS MIA��^�,���xo m oso/ep���so��p�xcso e /ws o mmm/ FL ' PURSUANT roCOUNTY CODE CHAPTER a«'ART. n& 10 pEnmn'�o.uz1 | � 220592-0 RENEWAL � BUSINESS NAME /LOCATION LICENSE NO. 091488-8 � CORNER HOUSE STATE #B11078 � 1895 SW ll TERR . ` 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type me"smess 213 ASSISTED LIVING FACILITY THIS ."^NOCCUPATIONAL EMPLOYEE/S 5 TA.X ONLY. rr DOES NOT PERMIT TH E LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR ooNOT FORWARD CMES. NOR DOES IT C, R PERMIT REQUIRED BY OF THECORNER HOUSE ����� ""^�"�- 1895 SW ll TERR MIAMI FL 33135 PAYMENT RECENED ' ����~�= V9/l3/2O04 30010000169 OOUl5O~VU u4 SEE OTHER SIDE /n|/',||�'./o/,U;/|]/]/lo,Ua}\nU/1/,,'/'1h\ro|!i Submitted Into thepublic' Priscilla A. Thompson City Clerk record in nnecti In ith n auamssoNAME /LocAnow CORNER HOUSE 1895 SW ll TERR 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type mBusiness THIS IS STED LIVING FACILITY TAX ONLY. 17 DOES NOT F'ERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CM S. NOR DOES IT EXEMPT THE UCENSEE ooNOT FORWARD FROM AM OTHER LICENSE OR PERMrr MOUIRED BY CORNER HOUSE 1895 SW ll TERR LICENSEES oU°,^ OF THE MIAMI FL 33135 TIKOL PAYMENT RECETVFD TA.X COLLECTOFL D8/O8/2O83 00290000060 000150.00 spsOTHER SIDE FIRST-CLASS � U.S.oaTxss � muoMIAMI, FIL ' PERMIT NO. 231 RENEWAL LICENSE NO. 09I488-8 STATE #B1I878 EMPLOYEES S [.IL,Uo/./i"Ii./\.|,[I.../I\...I I.'I I.I.I../i.),../I I I Submitted Into the public record .n connect', �nithh Priscilla A. Thompson City Clerk .-,.� .~-~-' MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 2002 OCCUPATIONAL LICENSE TAX 2003 MI,AMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2003 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A • ART. 9 & 10 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMfT NO. 231 220592-0 RENEWAL BUSINESS NAME/LOCATION LICENSE NO. 091486-8 CORNER HOUSE STATE #811878 1695 SW 11 TERR 33135 MIAMI OWNER EArlILY BOARDING HOME CORP Sec.Type of Business EMPLOYEES TillsLIAcuA,UPTED LIVING FACILITY 5 TAX ONLY. fT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE cowry OR CMES, NOR DOES fT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMfT REQUIRED BY LAW. THIS IS NOT A CER11F1CATION OF THE LICENSEE'S OUALIFICA. TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/28/2002 02100098§101 000150.00 SEE OTHER SIDE CORNE 1d55 MIAMI DO NOT FORWARD riLLS,z • 11 TERR L 3313') 1,,11.11.,,,11,,11„1,1„1,1,11,11„,11„11,1,1.1,11111111 Submitted Into the public record in connection w'th item pz.7.,- on 2- 244 Priscilla A. Thoripson City Clerk 2001 OCCUPA'T1ONAL UCENSE TAX 2002 MIAMI-DADE COUNTY - STATE OF FLORIDA 41•20-043:re14,-F • — EXPIRES SEPT. 30:2002 MUST BE DISPLAYED AT PLACE OF BUSINESS -7,:,;.1.--;:%-;•• Submitted Into the public record in connection ith item on g44 or Priscilla A. Thompson City Clerk MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 ; .PURSUANT TO COUNTY CODE CHAPTER 8A =•ART. 9 & 10 220592-0 BUSINESS NAME / LOCATION CORNER HOUSE 1B95 SW 11 TERR 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES, NOR DOES rr EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED EV LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA- TioN. PAYMENT RECEIVED MIAMI-DAOE COUNTY TAX COLLECTOR: 09/26/2001 02020180001 000150x4D0 SEE OTHER SIDE FIRST-CLASS , U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091488-8 STATE 4611878 DO NOT FORWARD CORNER HOUSE 1895 SW 11 TERR MIAMI FL 33135 EMPLOYEES 5 I II 11 l .;:i MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 Submitted Into the public record in connection vith item 2on Priscilla A. Thompson City Clerk 2000 OCCUPATIONAL LICENSE TAX 2001 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2001 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER BA - ART. 9 & 10 • 220592-0 BUSINESS NAME / LOCATION CORNER HOUSE 1895 SW 11 TERR 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY 5 THis,S AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REOUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. • FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091489-3 STATE 4311878 PAYMENT PECEIVED MIAMI.DADE COUNTY TAX COLLECTOR; 09/22/2000 88814m SEE OTHER SIDE DO NOT FORWARD CORNER HOUSE 1895 SW 11 TERR MIAMI FL 33135 EMPLOYEES DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 SubrnittedIntothepubHc recorclinconnectionwith iterrifton os" Priscilla A. ThotiipSOfl City Clerk 1999 OCCUPATIONAL LICENSE TAX 2000 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2000 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 220592-0 BUSINESS NAME / LOCATION CORNER HOUSE 1895 SW 11 TERR 33135 MIAMI FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091488-3 STATE 411878 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY, LT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES LT EXEMPT THE LICENSEE FROM WI OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS LS NOT A CERT- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/20/1999 030129003 000250.0D SEE OT1-(1241SIDE DO NOT FORWARD CORNER, HOU.SE 1:'795 SW 11 TERR MTA\II FL 33135 1 1111 I Hill 1.1111111 11111 DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 220592-0 BUSINESS NAME/LOCATION CCRNER HOUSE 1895 SW 11 TERR 33135 MIAMI Submitted Into the public record in connection wth item PZ • "- on 0-1P4 or Priscilla A. Thompson City Clerk 1998 OCCUPATIONAL UCENSE TAX 1999 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 1999 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANTTO COUNTY CODE CHAPTER 8A - ART. 9 & 10 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091488-3 STATE #B11878 OWNER FAMILY BOARDIN HOME CORP EM2LOTEES YirIVMsED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. R DOES NOT PERM THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CRIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER UCENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/16/1993 210000007 aCV-11.751%.43aal. DO NOT FORWARD CORNER HCUSE 1895 SW 11 TERR MIAMI FL 33135 SEE OTHER SIDE • I I 111111111 11111111 1111111 II 111 11111 111 Iwyjo.o ,11 AtlifYtitt State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE (with LIMITED MENTAL HEALTH) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: ARCADIA MANOR 1024 -26 S.W. 19TH AVE. MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 32 Optional State Supplementation Residents: 27 Private Pay Residents: 5 ary, Division of Health Quality Assurance 111 .1,tti` 41. , I 1. State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY (with LIMITED MENTAL HEALTH, LIMITED NURSING SERVICES) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: ARCADIA MANOR 1024 -26 S.W. 19TH AVE. MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 32 Optional State Supplementation Residents: 27 Private Pay Residents: 5 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: 0 0 0 EH.E,CTIVE DATE: 05/10/2000 ARCADIA MANOR 1024-26 S.W. 19TH AVE. MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 32 Optional State Supplementation Residents: 25 Private Pay Residents: 7 AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: 3 8 CT 13 -1 3 fp - Q. • ARCADIA MANOR 1024-26 S.w. 19th Ave. Miami, FL 33135 Dade County TOTAL CAPACITY: 32 Optional State Supplementation Residents: Private Pay Residents: 5 License 0005551 Number: • • . CAPACITY: 32 STN.' h OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION has complied with the rules and regulations adopted by the State of Florida, Agency for Health Care Administration as authorlz Part II, Laws o and is authorized to operate the following: Adult Congregate Living Facility ARCADIA MANOR 1024-26 S.W. 19TH AVE. MIAMI, FL 33135- Effective: 07/28/94 Expiration: 05/09/96 Submitted Into the public record in connection with item rz- 17- on ,-rn2Alor Priscilla A. Tho pson City Clerk Director Division of Health Quality Assurance JEB BUSH, GOVERNOR March 5, 2004 Ms. Leonore Gonzales, Administrator Arcadia Manor, ALF/LMH 1024 — 1026 S W 19 Avenue Miami, Fl 33135 Dear Ms. Gonzales: MARY PAT MOORE, INTERIM SECRETARY This letter confirms the findings of a full Biennial State Licensure survey of your Assisted Living Facility (ALF) with a Limited Nursing Services (LNS) and a Limited Mental Health (LMH) component, conducted on March 3, 2004 by Joseph Kraus, Health Facility Evaluator II, representing this office. Attached is your copy of the current Statement of Deficiencies State Form 2567 for ALF/LNS/LMH licensure Requirements, which lists that there were no deficiencies identified at your facility. In accordance with Chapter 400.435(3) of the Florida Statutes, a copy of this report of inspection must be posted in the facility in a prominent location so as to be accessible to all residents and the public. Your facility was found to be in compliance with licensure requirements of Chapter 400, Florida Statutes and Chapter 58A-5, Florida Administrative Code. Documents relating to State Licensure requirements will be made available for public disclosure as required by Florida law. A recommendation for a renewal ALF/LNS/LMH component will be forwarded to Tallahassee. If you have any questions, please contact Joseph Kraus, at (305)-499-2165. Sincerely, Diane Lopez, SN, ARNP Field Office Manager Enc. Statement of Deficiencies — 2567 cc: LTCOC/ALF UNIT Headquarters 2727 Mahan Drive Tallahassee, FL 32308 Submitted Into the public record in connection ith item 1)2. ??-- on Priscilla A. Thompson City Clerk www.fdhc.state.fLus Area Office 11 8355 NW 53"I street Manchester Building 1" Floor Miami, Florida 33166 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION December 18, 1996 Ms. Sofia Carratala, Administrator Arcadia Manor 1024-26 SW 19 Avenue Miami, FL 33135 Dear Ms. Carratala: A Standard license (#AL5551) has been issued to your facility for a capacity of 32 residents (5 private pay and 27 OSS) effective 7-9-96 through 4-8-98. If you need further assistance, please call me at (904) 487-2515. Sincerely, cq ine Henry Health Facilities Consultant Assisted Living Unit JH/jh cc: Karlene Peyton, Miami Area Supervisor Long Teriii Care Ombudsman Council, District 11 Administrator, District 11 (Dept. of Children and Families DOEA, Tallahassee,(V. Sims) Submitted Into the public record in connection with item In- 2.?-- on Priscilla A. Thompson City Clerk 2727 MAHAN DRIVE • TALLAHASSEE, FLORIDA 32308 LAWTON CHILES, GOVERNOR PRINTED; 3/11/2004 FORM APPROVED STATEMENT AND FLAN OF DEFICIENCIES OF CORRECTION (X1) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: ALF5551 (X2) MULTIPLE A. BUILDING B. WING CONSTRUCTION (X3) DATE SURVEY COMPLETED 3/3/2004 NAME OF PROVIDER OR SUPPLIER ARCADIA MANOR STREET ADDRESS, CITY, STATE, ZIP CODE 1024-1026 SW 19TH AVENUE MIAMI, FL 33135 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A 000 ` I l L l L L L L L L INITIAL COMMENTS An unannounced full biennial State licensure survey was conducted today. There were no deficiencies noted and a recommendation will be forwarded to Tallahassee for a renewal ALF/LNS/LMH license. A 000 Submitted Into the public record in connection ith item P7. »- on �-\Dos Priscilla A. Thompson City Clerk deficiencies are cited, an approved plan of correction is requisite to continued progra kBORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE participation. TITLE (X6) DATE TATE FORM V5NF1 If continuation sheet 1 of 1 JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY November 13, 2003 Ms. Leonore Gonzalez, Administrator Arcadia Manor ALF, ALF 1026 SW 19th Ave Miami, Fl 33135 Dear Ms Gonzalez: This letter confirms the findings of an unannounced Spot Check survey conducted at your facility on November 13, 2003 by Tabitha Hunter, Health Facility Evaluator I, representing this office. Attached is your copy of the current Statement of Deficiencies 2567 for ALF Licensure Requirements, which list that there were no deficiencies cited, upon completion of the survey. In accordance with Chapter 400.435(3) of the Florida Statutes, a copy of this inspection must be posted in the facility in a prominent location so as to be accessible to all residents and the public. Your facility was found to be in compliance with the licensure requirements of Chapter 400, Florida Status and Chapter 58A-5, Florida Administrative Code. Documents relating to State Licensure requirements will be made available for public disclosure as required by Florida law. If you have any questions, please contact Ms Tabitha Hunter at (305) 499-2165. Sincerely, Z6-4 "7 Diane Lopez -Castillo Field Office Manager Enclosure(s) : State Form 2567 Headquarters 2727 Mahan Drive Tallahassee, FL 32308 Submitted Into the public record in connection with item Pz. on ;tiler' Priscilla A. Thompson City Clerk www.fdhc.state.AUJ Area Office 11 8355 NW 53'd street Manchester' Building 1" Floor Miami, Florida 33166 Agency for Health Care Adminis ion PRINTED: 11 /19/2003 FORM APPROVED L STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) pROVIDEit/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11910367 (X2) MULTIPLE A. BUILDING B. WING CONSTRUCTION (X3) DATE SURVEY COMPLETED 11/13/2003 LNAME OF PROVIDER OR SUPPLIER ARCADIA MANOR STREET ADDRESS, CITY, STATE, ZIP CODE 1024-1026 SW 19TH AVENUE MIAMI, FL 33135 L(X4) ID PREFIX IAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A 000 L L L -� INITIAL COMMENTS A spot check survey was conducted at your facility on 11/13/03. Deficiencies were not cited. Arcadia Manor ALF was found to be in compliance with Assisted Living Facility Requirements. A 000 Submitted Into the public record in connection with item 7 . r'- on P}r4\os Priscilla A. Thompson City Clerk iCA Form 3020-0001 BORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE TE FORM 021199 WY901 If continuation shcct 1 of 1 THIS IS NOT A BILL DO NOT PAY This issuance o1 an occupational license does not permit the licensee to violate any zoning laws of the : city nor does It exempt the licensee from any other license or permits that rney be requiredby law.; This license does not constitute a certification that L the licensee Is qualified to engage in the business„. profession or occupation specified hereon. The license indicates payment of the occupational.`_ S 40. hggse tax only. . ()Cc # 051 7196 of Atia POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2004 THRU SEPT. 30, 2005 LICENSE FOR F Ai LY 3 R LJ1 = HDM ACCOUNT NO, OO93B5•-OO11e2S!i LICENSE NO. 096982-0001 ISSUED OCT 00) 2004 TOTAL FEE PAID NAME OF BUSINESS FAMILY BOARDING HOME INC LOCATION 1024 SW 19 AV FAMILY BOARDING HOME INC ARCADIA MANOR .1 O26' SW 1,9 AV 17 DCC 0 051 7f96 fAtizt POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708. MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2004 THRU SEPT. 30, 2005 LICENSE FOR F7Mti Y r3f1ARDING HOME INC ACCOUNT NO. 339386-001 1 tic 86 LICENSE NO. 096983-000 1 ISSUED ("I(: T (' A. ;1(1C)4 TOTAL FEE PAID NAME OF BUSINESS FAMILY BOARDING HOME INC LOCATION 1026 SW 19 AV TO 0) C cr FAMILY 13OARDING HOrIE INC ARCADIA MANOR .1026 SW 19 ,AV AM.I,; .L...: THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does It exempt the licensee from any When license or permits that may be required by law.. `-`.;'3': This license does not constitute a cenlficatlon that, „ the licensee Is qualified to engage In the business, profession or occupation specified hereon. The license indicates payment of the occupational", $40. ease Nu( only. DGC /I 051 7/96 t POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OH VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OE MIAMI P 0 EIOX 330708, MIAMI, FL 33233-0708 I- P -10NT (305) •41C-1570 ill-411111 LICENSE YEAR OCT. 1, 2003 THRU SEPT. 30, 2004 LICENSE FOR FAMILY f3OARDINO HOMf ACCOUNT NO 339386-00118218km LICENSE NO NAME OF BUSINEgyo.983—000r ©t r 1 003 FAMILY BOARDING HOME INC LOCATION 1026 SW 19 AV IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: • 4 , r tr. - .'4130ARDINGHOUSES TOTAL FEE PAID FAMILY BOARDING HOME INC TO 0". ARCADIA MANOR 1026 SW 19 AV MIAMI FL 33135-5129 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not Permit the licensee to violate any zoning laws of the city nor does it exempt the licensee trom any other license or permits that may be required by law, This license does not constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational license tax only. Si. 00 Elf CA 0 0-C 8 -5 ? 0 o-o DCG * 051 7/96 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OH VA L ID AT ANOTHER ADDRESS UNLESS APPROVED UV THE LICENSE SECTION, CITY OF MIAMI P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2003 THRU SEPT. 30, 2004 LICENSE FOR FAMILY BOARDING 140ME INC- ACGOUNT NO, 339385-001182p„_, LICENSE NO. ev 6982-0001 NAME OF BUSIN FAMILY BOARDING HOME INC LOCATION 1024 SW 19 AV IS HEREBY LICENSED TO ENGAGE IN OR MANAGE , .(:)pErIA:tptv OF: 11 lk.44 D-tNIG H OL1S' FS TO TOTAL FEE PAID FAMILY BOARDING HOME INC ARC AD IA MANOR 1026 SW 19 AV MtAMI FL 33135-5129 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not Permit the licensee to violate any zoning laws of the city nor does it exempt the licensee trom any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational license lax only. 5.40.00 FAMILY BOARDING HOME INC 339336-00113286 095983-00)1 )CT 18, 2302 FAMILY BOARDING HE INC 1026 SW 19 AV FAMILY BOARDING HOME INC 1cADIA MANOR 1)25 Su 19 Av MrAmI, FL 3335-5129 .18 ARDINGHOUSES y X FAMILY BOARDING HOME INC 339385-00118285 096932-0001 )CT 1°, 23C2 FAMILY BOARDING 4)ME ENC 1024 SW 19 AV FAMILY BOARDING HOME A?CAD[A MANOR 1)26 SW 19 AV MIAMI FL 33135-5129 [il DCC 051 7/96 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OH VALID ATANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1999 THRU SEPT. 30, 2000 LICENSE FOR 1- cmIL Y l'JDA_I.? Li LNGHOME Il1C ACCOUNT NO. 339335 —0U119285 LICENSE NO. 09698 2-0 on 1 ISSUED NAME OF BUSINESS F AMR Y EWARDI N LOCATION 1024 Sw 19 AV ISHEREBY LICENSED TO ,ENGAGE IN OR MANAGE THE OPERATION OF: - aoitclouNG4ouSES TOTAL FEE PAID FAMILY '60AR DI NG TO PI" ARCADIA MANOR 1)26 SW 19 AV HOME INC MIAMI FL 33135-5129 THIS IS NOT A BILL DO NOT PAY C:)cc, •4 phis issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licerviee from any other license or permits that may be required by law. This license does not conslilule a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational S40-00 license tax only. 0 = 0) 3 0 -13 ° Cc-URLYf giliami CERTIFICATE OF USE FIRE SAFETY PERMIT 000 0;Agrkt*G-*oftE • pttettv:ir, 31 3.5'4151(2 ' • HIS IS NOT A BILL DATE ISSUED: 02/ 20 /0 3 VALID FROM: oitoi/03 NOTICE: This cerlificate is Non -Transferable. II you relocale, sell the business, or change the type ol business a new certificate must be obtained from Building and Zoning al 444 S.W. 2nd Avenue, 4111 Floor, Phone: (305) 416-1199 1012/11/03 ACCOUNT NO: 3 3 9 3 8 6— / 82 35 3 , 4 SERVICE ADDRESS: 1026 Su 1 AV ''.APPROVED USE.: I SOF 1 RESTRICTIONS • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC 01065 (8/97) IX;C 051 7,96 Un nti POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1998 THRU SEPT. 30, 1999 LICENSE FOR F-A-M I INC ACCOUNT NO. .) 59J.io-J011 62 .) LICENSE NO, U 9 0 '1 6i-1-IL/GI ISSUED NAME OF OF BUSINESS Fi.:MILY ,:WAYUING HOP,3E L NC LOCATION 1 u 0 jlY A V TO IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: 30AkUINGHO6SE TOTAL FEE PAID FAMILY HOARDING HOME INC ARCADIA MANOR 1020 SW 1 Av r.105,t,r1 FL J3135-5129 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee 10 violate any zoning laws of the city nor does it exempl the licensee rrom any olher license or permits Mal may be required by law. This license does nol cunstituie a certification Thal the licensee is qualified lo engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational license taa only. .04Li.uU 1999 rA DGC 051 7/96 q_."-it120 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI, P.O. BOX 33070E1, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1998 THRU SEPT. 30, 1999 LICENSE FOR FAMILY iAARDING HOME INC AccouNr No. 3 3 9 $3 7 — 1 1 2 5 LICENSE NO. U9u9 6 2—LNO1 ISSUED OCT 0 2 # 9 98 TOTAL FEE PAID NAME OF BUSINESS FAMILY OA!•Z DIN MILINC LOCATION 102 4 S'Ai 1 AV IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: i3OARDINGFIOUS ES 1 TO 10' F FINLEY EOARDING HOME INC ARCADIA MANOR 1026 SW 19 AV miArli FL 33135-5129 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licensee from any other license or permits that may be required by law. This license does not constitute a certification Thal the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational 4 a. e0selaxooly. 1999 0 0 (!Jit cif Aiami CERTIFICATE OF USE FIRE SAFETY PERMIT ',' • • '•••••,- ••• ‘• • Z%-','191,,•••,':% LA ,„ THIS IS NOT A BILL DATE ISSUED: a I 2)/03 VALID FROM: 01/01/03 T°12/ .31/03 ACCOUNT NO: 3393as_ 1 82 349 SERVICE ADDRESS: 1024 ,SU1 ,19 AV n :APPROVED CISEfl ' • • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECC!ON DEL COMERC!O. NOTIGF: This certificate is Non-Transterable. If you relocate, sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue., 41h Floor, Phone: (305) 416-110 DOC #065 (8/97) C itu of tiami CERTIFICATE OF USE FIRE SAFETY PERMIT FAMILY BOARDING HOME a 2 6.$ rl 19 AV MIAMI:FL 33135-5129' THIS IS NOT A BILL DATE ISSUED: C 2 / !; 3 / VALID FROM: li 1 / C / NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue, 4I1i Floor, Phone: (305) 416-1199 To:17/31/ ACCOUNT NO: 339336- 162353 SERVICE ADDRESS: 1Cj26 SW 19 AV APPROVED USE: CU4-A.C.L. F. RESTRICTIONS: PROFIT - C.l. • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (6/97) (city rrf gietmi CERTIFICATE OF USE FIRE SAFETY PERMIT FAMILY BOARDING HOME 1026 sw 19 AV MIAMI FL33135-5129 THIS IS NOT A BILL DATE ISSUED: j; / ^ 3 /" VALID FROM: rl /:) ACCOUNT NO: 339385— SERVICE ADDRESS: 1024 SW - 9 AV APPROVED USE: CU1 5—C.B.R. F. NON—PROFIT RESTRICTIONS: NOTICE: This certificate is Non-Transferahle. If you relocate, sell the business, or change the type of business a new certificate must be obtained trom Building and Zoning at 444 S.W. 2nd Avenue, 4th Floor, Phone: (305) 416-1199 TO:12/31/.11 349 • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIb VISIBLE EN LA DIRF_CC!ON DEL COMERCIO. DOC 6065 (8/97( n (qu of tiami CERTIFICATE OF USE FTQF SAFFTY PPOMTT FAMrI Y RnaPrTLIG uf1MF 1n76 Cu 19 AV MT*M1 FI 11115-5179 THIS IS NOT A BILL DATE ISSUED: VALID FROM: n7/n5/nn n1/n1/nn NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate must he obtained horn Building and Zoning at 444 S.W. 2nd Avenue. 41h Floor, Phone: (305) 416-1199 T017/11inn ACCOUNT NO: 1 19 1 R h— 1 R 7 1 5 1 SERVICE ADDRESS: 1n7A Su 19 AV APPROVED USE: r111L—A_r.,I _.F_ PPrIFIT — r11- RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMEFICIO. r DOC 8065 (8/97) Cif r of c1i uni CERTIFICATE OF USE FTRF CAFFTY PFRMTT FAMTI Y FIf1A17nTNf. IdnMF 1n7A sw 10 Au MT AMT FI ii1 iS—S1 79 THIS IS NOT A BILL DATE ISSUED: n7inSinn VALID FROM: n 1/ ACCOUNT NO: 3393R5_ SERVICE ADDRESS: 1n76 Cu 19 AV NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate must he obtained irorn Building and Zoning at 444 S.W. 2nd Avenue, 41h Floor, Phone: (305) 416-1199 TO:1 7 ii1 Inn 1R7i60 APPROVED USE: f11T5—f_R,R F_• Nf1N—P0n;IT RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERT!FICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (8/97) 1 I 1 I 1 1 I I (! itR of Iirxmi CERTIFICATE OF USE FIRE SAFETY PERMIT THIS IS MDT A BILL DATE ISSUED: 0 3/ 0 6/ 9 9 VALID FROM: 01 / 01 / 9 9 NO [Act,- This cJrhhcale is Non Transferable. It you ielocate, sell the business, or change the type of business a new certificate must be obtained lull Building and Zoning al 444 S.W. 2nd Avenue, ,1111 Floor, Phone: (305) 416-1199 To:12/31 /99 ACCOUNT NO: 339386- 182353 SERVICE ADDRESS: :.102.6 SW t9.'A APPRdVED USE ,.CU1,4-A. C. RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (8/97) (c-itu of Atianti CERTIFICATE OF USE FIRE SAFETY PERMIT tinINWHyrallo HOME MIAMI FL 33135-5129 THIS IS NOT A BILL DATE ISSUED: 0 2 /07 / 9 8 VALID FROM: 3 1 /01 / 9 8 NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type ol business a new certificate must he obtained frorn Building and Zoning at 444 S.W. 2nd Avenue, 4th Floor, Phone: (305) 416-1199 To:12/31/98 ACCOUNT NO: 339386- 182353 SERVICE ADDRESS: 1026 SW 19 AV APPRDVED USE: CU14-A.C.L.F. RESTRICTIONS: PROFIT - C.U. • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCAT dN AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (8/97) i E 1 1 1 1 1 E I Cciiu of g[iami CERTIFICATE OF USE FIRE SAFETY PERMIT FAMILY BOARDING HOME 1026 SW 19 AV MIAMI FL 33135-5129 THIS IS NOT A BILL DATE ISSUED: 0 2/ 0 7/ 9 8 VALID FROM: 01 /0 1 / 9 8 NO TICE: [his certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue, 4)h Floor, Phone: (305) 416-1199 To:12/31/98 ACCOUNT NO: 3 3 93 d 5— 182349 SERVICE ADDRESS: 1024 Sid 19 AV APPROVED USE: CU15—C.B.R.F. NON—PROFIT — C.U. RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY. ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC 8065 (8/97) MIAMI-DADE COUNTY TAX COLLECTOR 14th FLOOR MIAMI, FL 33130 220591-2 BUSINESS NAME/ LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI 000^ oocupAnowAL LICENSE TAX uuno mmMI-oAosCOUNTY ' STATE opFLORIDA EXPIRES SEPT. oo 000s MUST BsompuYsnxrp���sopBUSINESS PURSUANT roCOUNTY CODE CHAPTER oa'ART. ym1n FIRST-CLASS u.o.POSTAGE pwm MIAMI, FL PERMIT NO. oa1 Taks AB/LL'DON0TPAY RENEWAL ucEwsE NO. 091495-3 STATE #811074 OWNER FAMILY BOARDING HOME INC Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS /s^wOCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE To VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EX EM PT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF TH E PAYMENT RECEIVED nm O9/l3/2004 30010000167 U0Ol54-2O SEE OTHER SIDE MIAMI-DADE COUNTY TAX COLLECTOR 14th FLOOR 220595-3 BUSINESS NAME /LouAnow ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI EMPLOYEE/3 5 DO NOT FORWARD ARCADIA MANOR 1026 3W 19 AVE MIAMI FL 33135 2004 OCCUPATIONAL LICENSE TAX uuns mmM+DADECOUNTY ' STATE oFFLORIDA EXPIRES SEPT. MUST oEDISPLAYED ATPLACE oF BunmEoo PURSUANT ToCOUNTY CODE CHAPTER ox'ART. oa10 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business nnor-CLAaa U.S. POSTAGE PAID MIAMI,FL PERMIT NO. RENEWAL LICENSE NO. 091493-8 STATE #D11874 EMPLOYEE/S 213 ASSISTED LIVING FACILITY 5 THIS IS AN DCCUPAT10NAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE To VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR ooNOT FORWARD CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTH ER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THEARCADIA MANOR LICENSEE'S"�"""° 1024 SW 19 AVE MIAMI FL 33135 PAYMENT RECEIVED pu U9/l3/2U04 30010000166 ODx,SDi-Ao SEE OTHER SIDE Submitted Into the BUSIN PS-SNAM$ / LOCATION ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI Submitted Into the public record in connecti n ith item P2.2z- on os Priscilla A. Th mpson City Clerk FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 THIS IS NOT A Bit-L-DO NOT -PAY WWpp�� RES�No• 091493-8 STATE BB11874 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business EMPLOYEES THIS IBA1 c,PAASLISTED LIVING FACILITY 5 TAX ONLY. 1T DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 08/08/2003 00290000056 000150.00 SEE OTHER SIDE BUaESSNAM? / LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI DO NOT FORWARD ARCADIA MANOR 1024 SW 19 AVE MIAMI FL 33135 iIIIl1IIII:I11111111:1i1IIIIIIIIIIIi1111111IT1,1111111111111i1 T A IL - OWNER SecFiypelofYBulia sRDING HOME INC hos 45,I5ISTED LIVING FACILITY TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXLSTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES n' EXEMPT THE UCENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION QF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 08/08/2003 00290000057 000150.00 SEE OTHER SIDE FIRST-CLASS U.S. POSTAG PAID MIAMI, FL PERMIT NO. 2' AY 091495-3 STATE BB11874 EMPLOYEES 5 DO NOT FORWARD ARCADIA MANOR 1026 SW 19 AVE MIAMI FL 33135 II I III I1111,1111111111117111111 II I1111111111111111111111111 111 MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 Submitted Into the public' record in connection w'th item P2.9-- on P- P risc,i I I a A. Tho ps n City Clerk 2002 OCCUPATIONAL LICENSE TAX 2003 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2003 MUST BE DISPL4YED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 220595-3 BUSINESS NAME / LOCATION ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI OWNER FAMILY THIS 1?Al ?CCUIATUAJ cTED TAX ONLY. R DOES NOT PERMR THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERPAR REQUIRED EY LAW. THIS IS NOT A CERTIFICATION OF THE UCENSEE'S OUALIFICA. TION. PAYMENT RE:CEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/26/2002 0210009601 000150.00 SEE OTHER SIDE MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 HOME CORP FIRST-CLAS; U.S. POSTAG PAID MIAMI, FL PERMIT NO. 2 RENEWAL LICENSE NO. 091493-8 STATE 11E11874 EMPLOYEES LIVING FACILITY 5 DO NOT FORWARD ARCALIi, MLN_R 1024 S 19 AVE MIAMI FL 3313:7, 2002 OCCUPATIONAL LICENSE TAX 2003 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2003 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 ilOS9S / LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI OWNER FAMILY 80ARDING HUME INC Sec. Type of Business FIRST-CLA: U.S. POSTAI PAID MIAMI, FL PERMIT NO. RENEWAL LICENSE NO. 091495-3 STATE #311674 EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES, NOR DOES IT EXEMPT THE UCENSEE FROM ANY OTHER UCENSE OR PERMIT REQUIRED BY LAW. THIS is NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMLOADE COUNTY TAX COLLECTOR: 09/26/2002 02100096401 000150.00 SEE OTHER SIDE DO NOT FORWARD ARCADIA MANOR 1026 SW 19 AVE MIAMI FL 33135 11 11,,,11„„11.11,,1,1"1,1„,,11,1,11,1",.1,1,11.,11.1 Submitted Into the public record in connection w'th item . ry on ''`4 Priscilla A. Thor-1pson City Clerk • MIAMI DADE COUNTY 1,c12001 {'�"� OCCUPATIONAL LICENSE TAX 144O AXW COLLECTOR ST . ,,*y T.Q. 2 , .EXPIR SNSEPT `30, 200kSTATE 2 LORIDA 14111 FLOOR -,tw MUST BE DISPLAYED AT PLACE OF%BUSINESS , MIAMI FL`33130 PURSUANT TO COUNTY CODE CHAPTER BA FART 9 & 10 ..f� Asti.. '�� a� -�" ��-i..a.: ..,�r.,. a_...._..'-.i.i�w eir�.j.1'sii+k.:�n:sK�Crla�:'�3ia.:'�, 220591-2 BUSINESS NAME / LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091495-3 STATE #B11874 OWNER FAMILY BOARDING HOME INC Sec. Type of Business EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW, THIS IS NOT A CERTIFICATION OF THE LICENSEES OUALWICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/26/2001 02020178001 00015o=.o0 SEE OTHER SIDE DO NOT FORWARD ARCADIA MANOR 1026 SW 19 AVE MIAMI FL 33135 MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 Submitted Into the public record in connectioh itemon Priscilla A. City Cp on lerk 2000 OCCUPATIONAL LICENSE TAX 2001 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2001 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 220595-3 BUSINESS NAME / LOCATION ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OP PERMIT REQUIRED BY LAW. THIS 15 NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMI-CADE COUNTY TAX COLLECTOR: 09/22/2000 050348001 000150.00 SEE OTHER SIDE MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 5 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 2: RENEWAL LICENSE NO. 091 4 9 3-8 STATE t#311874 DO NOT FORWARD ARCADIA MANOR 1024 SW 19 AVE MIAMI FL 33135 EMPLOYEES 5 2000 OCCUPATIONAL LICENSE TAX 2001 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2001 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 220591-2 BUSINESS NAME / LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI RENEWAL LICENSE NO, 09 STATE OWNER FAMILY BOARDING HOME INC Sec. Type of Business EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OP ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW, THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION, PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/22/2000 050349001 000150.00 SEE OTHER al DO NOT FORWARD ARCADIA MANOR 1026 SW 19 AVE MIAMI FL 33135 6,1 :;1:111111111111 FIRST-CLA: U.S. POSTAI PAID MIAMI, FL PERMIT NO. 495-3 311874 DADE COUNTY TAX COLLECTO1 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 220595-3 BUSINESS NAME / LOCATION ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI Submittedintothepublic manlinoonnectio with item Pz-P-a-on Or Prisala A. Tho pson City Clerk 1998 OCCUPATIONAL LICENSE TAX 1999 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 1999 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CiRDE CHAPTER 8A - ART. 9 & 10 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CTES. NOR DOES IT EXEMPT THE UCENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE UCENSEE'S QUALIFICA- TION, PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/16/199° 210000010 eaftein.d SEE OTHER SIDE DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091493-8 STATE #611874 DO NOT FORWARD ARCAD7A MA:1CP 1024 4 19 AV: MIAMI 71_ 33137 220591-2 BUSINESS NAME LOCATION ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI EMDLOY ES 1998 OCCUPATIONAL LICENSE TAX 1999 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 1999 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 OWNER FAMILY BOARDING HOME INC Sec. Type ot Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. rr DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE UCENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/16/1998 210000E329 00015044i0 SEE OTHER SIDE FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091495-3 STATE #',11874 DO NOT FORWARD ARCADIA MANOR 1026 SA 19 AVF: MIAMT 7L 3312 EMPLCYEES 111111111111111111111 I I II 11 III 111lt 1)11111111111 DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 Submitted Into the public record in connection with item P2. 2- on ?•124)06 Priscilla A. Thompson City Clerk 1999 OCCUPATIONAL LICENSE TAX 2000 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2000 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER BA - ART. 9 & 10 220595-3 BUSINESS NAME / LOCATION ARCADIA MANOR 1024 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES, NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER UCENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/20/1999 030129005 000150.00 SEE OTHER SIDE DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 'FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 23 RENEWAL LICENSE NO. 091493-8 STATE #B11874 DO NOT FORWARD ARCADIA 1024 Sw 19 AV FL 3313:7 LOYEES 5 1999 OCCUPATIONAL LICENSE TAX 2000 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2000 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER BA - ART. 9 & 10 FIRST-CLASE U.S. POSTAGI PAID MIAMI, FL PERMIT NO. 2: 220591-2 RENEWAL BUSINESS NAME / LOCATION LICENSE NO. 091495-3 ARCADIA MANOR 1026 SW 19 AVE 33135 MIAMI STATE #B11874 OWNER FAMILY BOARDING HOME INC Sec. Type of Business EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY. FT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/20/1999 0301'29004 000150.00 SEE OTHER SINS DO NOT FORWARD ARCADIA MANIOR 1025 SW 19 AVE MIAMI FL 33135 I 11111 I 11111111 I I11111111111111 I 11 110 II III ! I tl 11 VS* State of Florida AGENCY FOR HEALTH CARE ADMINISTRA DIVISION OF HEALTH QUALITY ASSURANCE This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part Ill, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: ARCADIA MANOR SOUTH 1144 SW 19TH AVENUE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 12 Optional State Supplementation Residents: 11 Private Pay Residents: j. y, Division of Health Quality Assurance .4f 11.11441 r i 111$ Oki I Lra:ti wot , f f II 4b;" 'LLU.Lh_qa! CERTIFICATE #: 13233 t., # - - +111i;11"14 1411 fAtill ' L State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY LICENSE #: AL5563 ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD is is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: cf) o c 3 0- -1) EFFECTIVE DATE: 05/10/2002 EXPIRATION DALE: 05/09/2004 , • .. • ARCADIA MANOR SOUTH 1144 SOUTHWEST 19TH AVENUE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 12 Optional State Supplementation Residents: 11 Private Pay Residents: 1 Deputy Secretary, Division fManaged Care and Health Quality rtil7 4:. -T-fri,aivii , /op CERTIFICATE #: 8417 LICENSE #: AL5563 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD is is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: ARCADIA MANOR SOUTH 11/14 SOUTHWEST 19TH AVENUE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 12 Optional State Supplementation Residents: 11 Private Pay Residents: 1 EFFECTIVE DA lb: 05/10/2000 EXPIRATION DATE: 05/09/2002 Deputy Director, Dihi1 of M ged Care and Health Quality iv* T 'AO t "Rd Y'Y'4 'two .0.ifff IrfivT t'4 CERTIFICATE #: 6931 LICENSE #: kL5563 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: m 3 8 cr ARCADIA MANOR SOUTH 1144 Southwest 19th Avenue Miami, FL 33135 v 8 Dade County TOTAL CAPACITY: 12 V ,10 Optional State Supplementation Residents: 11 a) Private Pay Residents: 1 Oro c cr EFFECTIVE DATE: 05/10/1998 EXPIRATION DATE: 05/09/2000 T4. ifloy t's I 4tAti iSCUIN 17'1;14;itiitiq 7 Clifittbajv At. • 47.7,6:. Nog 011:11 i T. lilt I I CERT1FICATb #: 6967 LICENSE #: AL5563 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: CD a3 3 8 8- a 3. EFFECTIVE DA I h: 05/10/1998 EXPIRATION DAM: 05/09/2000 /04 ARCADIA MANOR SOUTH 1144 Southwest 19th Avenue Miami, FL 33135 Dade County TOTAL CAPACITY: 12 Optional State Supplementation Residents: 11 Private Pay Residents: 1 ; Deputy Director, Di ' of M aged Care ve ealth Quality JEB BUSH, GOVERNOR March 5, 2004 Ms. Leonore Gonzales, Administrator Arcadia Manor South, ALF/LMH 1144 S W 19 Avenue Miami, Fl 33135 Dear Ms. Gonzales: MARY PAT MOORE, INTERIM SECRETARY This letter confirms the findings of a full Biennial State Licensure survey of your Assisted Living Facility (ALF) with a Limited Mental Health (LMH) component, conducted on March 3, 2004 by Joseph Kraus, Health Facility Evaluator II, representing this office. Attached is your copy of the current Statement of Deficiencies State Form 2567 for ALF/LMH licensure Requirements, which lists that there were no deficiencies identified at your facility. In accordance with Chapter 400.435(3) of the Florida Statutes, a copy of this report of inspection must be posted in the facility in a prominent location so as to be accessible to all residents and the public. Your facility was found to be in compliance with licensure requirements of Chapter 400, Florida Statutes and Chapter 58A-5, Florida Administrative Code. Documents relating to State Licensure requirements will be made available for public disclosure as required by Florida law. A recommendation for a renewal ALF/LMH component will be forwarded to Tallahassee. If you have any questions, please contact Joseph Kraus, at (305)-499-2165. Sincerely, lane Lopez, Field Office Manager Enc. Statement of Deficiencies State Form — 2567 cc: LTCOC/ALF UNIT Headquarters 2727 Mahan Drive Tallahassee, FL 32308 Submitted Into the public record in connecti n wth item n. 2.,2- on P.- s- Priscilla A. Tho pson City Clerk yewy.fdhc.state.fLus Area Office 11 8355 NW 53'd street Manchester Building 1" Floor Miami, Florida 33166 STATEMENT OF DEFICIENCIES AND PLAN QF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05563 (X2) MULTIPLE A. BUILDING B. WING CONSTRUCTION (X3) DATE SURVEY COMPLETED 3/3/2004 LNAME OF PROVIDER OR SUPPLIER ARCADIA MANOR SOUTH STREET ADDRESS, CITY, STATE, ZIP CODE 1144 SW 19TH AVENUE MIAMI, FL 33135 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A 000 N INITIAL COMMENTS An unannounced full biennial State licensure survey was conducted today. There were no deficiencies noted and a recommendation will be forwarded to Tallahassee for a renewal ALF/LMH license. A 000 Submitted Into the public record in connect) item Via`?' on ? Priscilla A. T Cityho ClerkPon —If deficiencies are cited, an approved plan of correction Is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE —'STATE FORM 021199 O8RU1 If continuation sheet 1 of 1 0 0 "ti m g 0 @ 3 8 cr. a 3 , 51f o a o • 0 „R 0 V 0 7:3 1 *. 0 Nre •-,:,••••••••••':•-••.-.i,”•:•,,- • t.7!:•4•••••••'14; • 4.trf.••,..•,.- • • °CC if 05 I 7/95 LICENSE FOR POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0706 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2004 THRU SEPT. 30, 2005 FAMILY BOARDING HOME INC ACCOUNT NO, 339392-001 18290 LICENSE NO 0989E37-0001 ISSUED OCT 08, 2004 TOTAL FEE PAID NAME OF BUSINESS F AM I LY BOARD I NG HOME I NC LOCATION 1 144 SW 19 AV 1:$1-1EREBY LICENSEDi TO ENGA0E114:0R1VANACIE FAMILY BOARDING HOME INC TO 10. ARCADIA MANOR SOUTH 1144 SW 19 AV THIS IS NOT A BILL DO NOT PAY This issuance of an occupation& license does not permit the licensee to violate any zoning laws of the city nor does It exempt the licensee from any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational license tax only. $40. 00 • "AT.--' MCO0b17195 f AIM LICENSE FOR ACCOUNT NO. 339392-0011 8290 LICENSE NO. 096987-0001 ISSIJED NAME OF BUSINESS FAMILY BOARDING MIME INC LOCATION 1144 SW 19 AV POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2003 THRU SEPT, 30, 2004 FAMILY BOARDLNG NOME INC IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OpERATION OF: T4',/ - *ROI NG NOUS FAMILY BOARDING HOME INC TO 0. APCAD IA MANOR SOUTH 1144 SW 19 AV MIAMI FL 331 35 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licensee from any other license or permits that may be required by law. This license does riot constitute a certification that the licensee Is qualified to engage in the business, profession or occupation specified hereon. , The license indicates payment of the occupational license tax only. OCT 10, 2003 TOTAL FEE PAID S40.00 74: (3 3 0 c cr :,0 -a a 3 cw C.4 a NI 0- 0 •-••• „to 0 V FAMILY 3OARDING HOME INC 339392-0J118290 046987-0001 3CT 18o 2002 FAMILY BOARDING HOME INC 1144 SW 19 AV • Li( ill:-%1.?,r)iiRATACti`',1 OF. • , . • N CD 0 CI. 0 -- 51 5 13 5' a) 71:3 -* 5-- 5 \-, ROARDINGHOUSe8J FAMILY BOARDING HOME INC ARCADIA MANOR SOUTH 1144 SW 19 AV ,MIAMI FL 33135 • (2 Xi: (i) (D 3 8 5- a. 3. .1.) 0 a • o D a r • ODO (.9 3 ZIT ( IXC 1051 MB POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHEF1ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2001 THRU SEPT. 30, 2002 LICENSE FOR FAMILY BOARDING HOME INC 39392— aita29r.1 96987 aril OCT 12, 2001 LIC'ENSE NO. FAM LY BOIRHIIN" HOME INC NAmE Busirn 4 $ W 9 A V LOCATION . 1$ HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: BOARDINGHOUSES TOTAL FEE PAID r FAMILY BOARDING HOME INC ARCADIA MANOR SOUTH TO 144 SW 19 AV MIAMI FL 33135 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licensee tiom any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business, prolession or occupation specified hereon. The license indicates payment of the occupational $41:), ()Se tax -; CD CD c 3 OOcr, - 0 - ,. -0 0- -• 0 • 74. CD • C) 0 DCG P 651 796 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2000 THRU SEPT. 30, 2001 LICENSE FOR E A PIT 1 Y RotRO (NZ HONE I NC ACCOUNTNO, 339392-00118290 LICENSE NO. 096987-0001 ISSUED flc:T nei. 7nlin TOTAL FEE PAID NAME OF BUSINESS FAMILY BOARDING HOME INC LOCATION . 1144, SU 19 AV r- TO lk• IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: BOAROINGHOUSES FAMILY BOARDING HOME INC ARCADIA MANOR SOUTH 1144 Su 19 AV MIAMI FL 33135 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws or the city nor does it exempt the licentiee nom any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualifiecl to engage In the business, profession or occupation specified hereon. The license indicates payment of the occupational $ 4.15bse tax only. DQC N 051 7d96 Titu POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1999 THRU SEPT. 30, 2000 LICENSE FOR F AMIE Y ROAROING HOHT T?lI( ACCOUNT NO. 33 9 39?A••••0011 8?Wl LICENSE NO 09 69R 7.•••000 1 ISSUED 3( r niar g9 TOTAL FEE PAID NAME OF BUSINESS f AMILY BOARDING ocirrioN • 1144 SW 19 A V IS HERESY LicENSED•TO • ENGAGE IN OR MANAGE THE OPERATION OF , ! A USfS r TO II" IMF FAMILY BOARDING HOME INC AWCADIA MANOR SOUTH 1144 SW 19 AV MIA141 FL 3 31 3 S THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licniv..ee from any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational Niise tax only. OC;C: 4 091 7/96 LICENSE FOR POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 1998 TH U SEPT. 30, 1999 ACCOUNT NO. 339392-00116290 LICENSE NO. 096967-0001 ISSUED OCT 02.19 NAME OF BUSINESS FAMILY HOARDING HOME INC LOCATION 114 4 S W 19 AV TO 11' IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: .tc ARDIN4HOUSES TOTAL FEE PAID FAMILY ECARDING HOME INC ARCADIA MANOk SOUTH 1144 Sit 19 AV MIAMI FL 33135 110011111111111111•111..1111•111. THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licensee nom any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business. profession or occupation specified hereon. The license indicates payment of the occupational license lax only. i4O.UU (gll! of ciftimati CERTIFICATE OF USE fr THIS IS NOT A BILL DATE ISSUED: ,),P 9 / .9 2 VALID FROM: .3 f ACCOUNT NO: SERVICE ADDRESS: 1 1 4 S. id 1 AV APPROVED USE: O.^^- RESTRICTfONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO it of Atiami CERTIFICATE OF USE F F.“' SAFETY PM1r FAMILY ARDING HOME 4144 Simi AV MIAMI FL 53135-51 51 NOTICE: This certificate is Non-TranSterable. if you relocate. sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. end Avenue. 4th Floor: Phone: (305) 416-1199 1-(411L12; THIS IS NOT A BILL DATE ISSUED: 0 2 I 0 3 VALID FROM: if 5 DOC #065 (8/97) NOTICE: This certificate is Non -Transferable. you relocate. sell the business, or change the type of business e new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue, 4th Floor. Phone: (305) 416-1199 TO 1 1 ;11, ACCOUNT NO: 3 9 ? — 1 2 SERVICE ADDRESS: 1144 Si 1 AV APPROVED USE: P.F. NON—P;40F IT RESTRICTIONS: C U • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO DOC #065 (8/97) 3 8 Er IF a 3. (n. • a 0 • 0R• 0 Dw•-4- V 5.(1) -a ce Cc-UR of „Miami CERTIFICATE OF USE FIRE SAFETY PERMIT F PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. L• FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. THIS IS NOT A BILL DATE ISSUED: 221 23/34 VALID FROM: 01 / Ell /04 NOTICE: This certificate is Non-Translerable. If you relocate, sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W 2nd Avenue. 4th Floor, Phone: (3054 416-1199 Tot 2/ 3'1 /C4 ACCOUNTNO: 339392- 515956 SERVICE ADDRESS: 1144 SW Av APPROVED USE: CU2d-C..H NON-P-ROFIT - RESTRICTIONS: Cite of Aim/1i CERTIFICATE OF USE FIRE SAFETY PERMIT FANTIEY dUAROIN:, momE 1144 Sw 19 AV MIAMI FL 33135-5131 THIS IS NOT A BILL DATE ISSUED: )2/ 2134 VALID FROM: tJ /0/ /04 C. U. NOTIC: This certificate is Non-Transterable. If you relocate, sell the business, or change, the type of business a new certificate must he obtained from Building and Zoning at 444 S.W. 2nd Avenue. 4th Floor. Phone: (3051416-1199 T012/ 7,1/P4 AGCOUNT NO: 3 39392— 182152 SERVE f:opnssi A APPe9yri) J. F RESTRICTIONS: 10N-PPOFET - C.0 • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (8/97) CD CD rr c-3. 3. • CD V 0 O — • 0 (cifu ctf „Miami CERTIFICATE OF USE SAFTY PIT FAMILY ,v;',A14DI4i3 HpmF r:3W AV MIA,oI FL DATE ISSUED: VALID FROM: NOT A BIL 1, 1 1 / ACCOUNT NO: SERVICE ADDRESS: —44 SW AV APPROVED USE: RESTRICTIONS: TO: N Thi—Jicate iv,' I-Tranieiaoie. you relocate. sell the business, or change the tyF oi business a new certificate must be cbtainc from Building and Zoning al 444 S.W. 2n Avenue, 4th Floor, Phone: (305) 416-1199 • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCAT ON AT OCCUPANCY ADDRESS. • FA VOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. Ccitu af CERTIFICATE OF USE FIFE SAFETY PER'4IT FAmILY i')ARDING HrImF 1144 SW 1? AV NIIAMI FL 33135-5131 THIS IS NOT A BILL DATE ISSUED: 1 517.2 VALID FROM: ACCOUNT NO: 332- 74?35? SERVICE ADDRESS: 1144 APPROVED USE: C015-C. F. NON-72FIT - C.O. RESTRICTIONS: DOC #065 (8/97) NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue. 4th Floor, Phone:, (305) 416-1199 )1101n? • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. TO: • 12/31VR DOC 8065 (EV97) cn 0 c cr -u —1 3 -0 ct N E"D' N) CI) 0 7 0 0 • QI3 .cD 3 -a 0 -a cr itu of Aliarni CERTIFICATE OF USE FJRE SAFETY PERMIT 1) FAMILY d. AHOING HOME 1144 Sw 19 AV MIAMI FL 3 31 35— 1 31 THIS IS NOT A BILL DATE ISSUED: 33/06/99 VALID FROM: al ./ Di /99 To:12/3 ACCOUNT NO: 33939 2— 182352 SERVICE ADDRESS: SW 19 AV APPROVED 5Du.T.;, R RESTRICTIONS: NOTICE: This certificate is Non-TransferabIe. If you relocate. sell the business. or change the type ol business a new certificate must be obtained from Building and Zoning at 444 S W. 2nd Avenue, 4fin Floor. Phone: (305) 416-1199 / 9 ON —PROFIT — C.U. • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERT/ROAD° EN UN SITIO VISIBLE EN LA D!RECCION DEL COME.RO/0, (LJi1 f 41tiami CERTIFICATE OF USE FTPR SAPTY OFAMIT AMTI y 1411AR1)T fur. wnatc 1144 St., 19 av mtami I331AS—S1A1 THIS IS NOT A BILL DATE ISSUED: n? ins inn VALID FROM: nijni inn ACCOUNT NO: SERVICE ADDRESS: 114 & W 1 AJ APPROVED USE: rill s —1" _ _ _ RESTRICTIONS: 1R7AS7 DOC 0065 (8/97) NOTICE: This certificate is Non -Transferable. If you relocate. sell the business, or change the type ot business a neoi certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue, 4th Floor. Phone: t:305) 416-1199 ? nn Alnki—P r T — C1L • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIFIEOCION DEL COMERO;0. DOC #065 (6/97) if a; co a. 3 5' a; 0 0- 0 z 0 D- o 3 -o CD 0-o c3 o- Fr (Eitv o-f CERTIFICATE OF USE FOR BILLING INFORMATION CALL: 372-4690 FAMILY BOARDING HOME 1144 SW 19 AV MIAMI FL 33135-5131 THIS IS NOT A BILL DATE ISSUED: 1 2113197 VALID FROM: 01/0119 7 NOTICE: This certificate is Non-Transterablo. you relocate, sell the business, or change the typ of business a new certificate must be obtaine, from Building and Zoning at 444 S.W. 2n. Avenue, 4th Floor, Phone: (305) 416-1199 • TO:12 31 / 97 ACCOUNT NO: 330392- 182352 SERViCf4AleFTV:19 AV NE.C1D5uTOM,MUkITY BA S ED RE'S I DENT RESTRICTIONS: FAC NON-PROFIT • PLEASE DISPLAY' THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. (4itv of Aiartti CERTIFICATE OF USE, FIRE SAFETY P.ERIIT AmtLY 30AR, DINI6 HOmE 1144 Sw 19 AV MLA' I FL 311 ?,5-5131 THIS IS NOT A BILL DATE ISSUED: 62/07798 VALID FROM: U1/U1 19. ACCOUNT NO: 359392— 182352 SERVICE ADDRESS: 1144 SW 14 AV APPROVED USE: RESTRICTIONS: DOC 41065 (7/96) NOTICE: This certificate is Non -Transferable. If you relocate, sell the business, or change the type of business a new certificate most be obtained from Building and Zoning at 444 S.W. 2rid Avenue, 4th Floor, Phone: (305) 416-1199 TO: 121 3 1/ 98 ON—PFIGF — C.U. - PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC 0060 (8i97) (D cn ..�3ov a • — v 0 N v O o (D i+ O CD C I? 14th FLOOR MIAMI, FL 33130 au, MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER BA - ART. 9 & 10 THIS IS NOT A BILL -DO NOT PAY 220593-8 RENEWAL BUSINESS NAME / LOCATION LICENSE NO. ARCADIA MANOR SOUTH 091490-4 1144 SW 19 AVE STATE #B11872 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA• TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/13/2004 30010000170 0001503.90 SEE OTHER SIDE MIAMI-DADE COUN TAX COLLECTOR., 7.,,, 1140 W. FLAGLE �.ST. 41 14th; FLOOR; :- , r MIAMI; FL33130:; BUM / LOCATION ARCADIA MANOR SOUTH 1144 SW 19 AVE 33135 MIAMI OWNER Sec QMIo BOARDING HOME CORP ype o usiness EMPLOYEE'S 5 DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 I ji !2111i141111111I 111111!! 111111I OCCUPATION' 'ICES ADEICOUSTATED PIRESISEPTh3Q 200;; MUSTS ISPLAYED"ATTPL ACE OF, SU NT"TOVOUN , a CODEt ER.8 TES ISMOT Hf 11.1.-1.#;..`,....a-1 IRW091490-4 STATE #B11872 kID MIAMI, FL PERMIT NO. 231 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 EMPLOYEES TNISISAgC PA4Ax.ISTED LIVING FACILITY 5 TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA. TION. PAYMENT RECEIVED MIAMI•DADE COUNTY TAX COLLECTOR: 08/08/2003 00290000058 000150.00 SEE OTHER SIDE DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 ! 111111111111111111111111,11! 111111I11 11111111 220593-8 BUSINESS NAME / LOCATION ARCADIA MANOR SOUTH 1144 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business THIS IMacuaw STLD LIVING FACILITY TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES, NOR DOES FT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY FAX COLLECTOR. 09/26/2002 ono009001 000150.00 SEE OTHER SIDE InI U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091490-4 STATE #B11872 DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 lulluilli EMPLOYEES 5 A :Ci ; •';:. :}.• 0 ;.;i'l,.•i:L: .....c..-:':-.,1,:i .: I,`0.' i.if i)':- - ,...!!...;,..„1; •1'.,..-,I,..c.1.I.‘Ii :,' 0.:•,:;:, ;,: ...y. :01.;rII...,A, ....,....;!r1.4::,,•:•., 0.,',..-:.!..,Y, •.,i..1 .2I-,c:I', 0.,i-, i.,,, ,•11-..;•...;\..‘,,:?::T. ,---, ',H ,.,';T. ''.:1,. :•:."').:,'.0.F-3.. •,,, j....-,-i,,,.....:,,,,,f iii,,,.,•,..,-;i:10;“...i,.',..,0i....i.::: Al?.[?.,7).i',.,',.:i ..i... • ::‘,.l1 ,;)..;!.• qtf) Z20593-6 BUSINESS NAME / LOCATION ARCADIA MANOR SOUTH 1144 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES. NOR DOES IT EXEMPT THE UCENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF 11.1E LICENSEES QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/26/2001 02020181001 00015%40 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091490-4 STATE #B11672 DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 EMPLOYEES 5 LjkA-11-11,Lijj-,MA_Hj.J.LJLA tp Ci) "1-1 3 crc a cn 74: • Q. • cia) oo m 0 0 220593-8 BUSINESS NAME / LOCATION ARCADIA MANOR SOUTH 1144 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A GERD- FICATION OF THE LICENSEE'S OUAUFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/22 2000 050347001 000150.00 SEE OTHEIME DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. •14th FLOOR MIAMI, FL 33130 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 22 RENEWAL LICENSE NO. 091490-4 STATE 41311872 DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 EMPLOYEES 5 Ildl,th.AillidIAVIdittv.14:&,,m0111:14i111114 1999 OCCUPATIONAL. LICENSE TAX 2000 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2000 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 220593-8 RENEWAL BUSINESS NAME/LOCATION LICENSE NO. 091490-4 ARCADIA MANOR SOUTH STATE #B11872 1144 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CMES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR: 09/20/1999 030129002 noniqn.nn DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 EMPLOYEES 5 DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 1998 OCCUPATIONAL LICENSE TAX 1999 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 1999 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANTTO COUNTY CODE CHAPTER 8A - ART. 9 8 10 220593-8 BUSINESS NAME / LOCATION ARCADIA MANOR SOUTH 1144 SW 19 AVE 33135 MIAMI OWNER FAMILY BOARDING HOME:: CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS 15 AN OCCUPATIONAL TAX ONLY. FT DOES NOT PERMIT THE LICENSEE TO VIOLA). ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CTGES. NOR DOES IT EXEMPT THE UCENSEE FROM ANY OTHER UCENSE OR PERMIT REQUIRED SY LAW. THIS IS NOT A CERTI- FICAHON OF THE LICENSEES QUALIFICA- TION. PAYMENT RECEIVED DADE COUNTY TAX COLLECTOR; 09/16/1998 210000011 SEE OTHER SIDE FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 091490-4 STATE #B11372 DO NOT FORWARD ARCADIA MANOR SOUTH 1144 SW 19 AVE MIAMI FL 33135 EMPLOYEES 5 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part HI, laws of the State of -Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: PINES 1800 SW 11TERRACE MIAMI, 1-L 33135 DADE COUNTY TOTAL CAPACITY: 12 Optional State Supplementation Residents: 10 Private Pay Residents: 2 ary, Division of Health Quality Assurance ..:411(11.314111 CERTIFICAIE #: 8514 40i fEllip e11.'':*;••'vee•,,k.:;•i;',-- NA: If 40,4 •11. V 41414.11, itt Will441:it A State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY LICENSE #: AL5438 ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and . with 58A-5, rules of the State of Florida and is authorized to operate the following: cn PINES cr 1800 S.W. 11TH TERRACE MIAMI, FL 33135 DADE COUNTY 0 EFFECTIVE DATE: 05/10/2002 EXPIRATION DA 1 E: 05/09/2004 TOTAL CAPACITY: 12 Optional State Supplementation Residents: 10 Private Pay Residents: 2 Deputy Secretary, Division4fManaged Care and Health Quali Xo%11 7 7 of ItifFrri 4111$1111tO I - - reivk 7 my, t,:f;''r flr" Tir7f y • w CERTIFICATE #: 8514 LICENSE #: AL5438 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY (with LIMITED MENTAL HEALTH) STANDARD This is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: EFFECTIVE DAIL: 05/10/2000 EXPIRATION DA FE: 05/09/2002 PINES 1800 S.W. 11TH TERRACE MIAMI, FL 33135 DADE COUNTY TOTAL CAPACITY: 12 Optional State Supplementation Residents: jQ Private Pay Residents: 2 Deputy Director, Div.sion of M(aged Care and ealth Quality -ftxtx, 7 746•47takYiNct'ef 111:+4;ik 'efetlitY87,7 vire; % 4,7071 "t4:71,141,01.7 4" 4 j,ttAtatti...;..1, (Lai CERTIFICATE #: 6785 t I • State of Florida 11 P. 11'14.1'w trtn, LICENSE #: AL5438 AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY ASSISTED LIVING FACILITY STANDARD is is to confirm that FAMILY BOARDING HOME, INC. has complied with Chapter 400, Part III, laws of the State of Florida and with 58A-5, rules of the State of Florida and is authorized to operate the following: F7 CB CA PINES a 3 1800 S.w. llth Terrace . Miami, FL 33135 o. o Dade County V S 5 - • aa o TOTAL CAPACITY: 12 o 7- co Optional State Supplementation Residents: 10 Private Pay Residents: 2 0, EFFECTIVE DA 1h: 05/10/1998 EXPIRATION DATE: 05/09/2000 Deputy Director, Di of M aged Care and Health Quality JEB BUSH, GOVERNOR March 5, 2004 Ms. Leonore Gonzales, Administrator Pines, ALF/LMH 1800 S W 11 Terrace Miami, Fl 33135 Dear Ms. Gonzales: MARY PAT MOORE, INTERIM SECRETARY This letter confirms the findings of a full Biennial State Licensure survey of your Assisted Living Facility (ALF) with a Limited Mental Health (LMH) component, conducted on March 2, 2004 by Joseph Kraus, Health Facility Evaluator II, representing this office. Attached is your copy of the current Statement of Deficiencies for ALF/LMH licensure Requirements, which lists that there were no deficiencies identified at your facility. In accordance with Chapter 400.435(3) of the Florida Statutes, a copy of this report of inspection must be posted in the facility in a prominent location so as to be accessible to all residents and the public. Your facility was found to be in compliance with licensure requirements of Chapter 400, Florida Statutes and Chapter 58A-5, Florida Administrative Code. Documents relating to State Licensure requirements will be made available for public disclosure as required by Florida law. A recommendation for a renewal ALF license with an LMH component will be forwarded to Tallahassee. If you have any questions, please contact Joseph Kraus, at (305)-499-2165. Sincerely, an Lopez, MN, ARNP Field Office Manager 'Enc. Statement of Deficiencies — 2567 cc: LTCOC/ALF UNIT Headquarters 2727 Mahan Drive Tallahassee, FL 32308 Submitted Into the publie record in connecti n ith item P2. 24- on ?- Priscilla A. Thohipson City Clerk www.fdhc.state.fl. us Area Office 11 8355 NW 53" street Manchester Building 1" Floor Miami, Florida 33166 . OF DEFICIENCIES ,N OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: PINES (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 3/2/2004 NAME OF PROVIDER OR SUPPLIER PINES STREET ADDRESS, CITY, STATE, ZIP CODE 1800 SW 11 TERRACE MIAMI, FL 33155 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A 000 INITIAL COMMENTS An unannounced full biennial State licensure survey was conducted today. There were no deficiencies noted and a recommendation wil(-be forwarded to Tallahassee for a renewal ALF/LMH license. A 000 Submitted Into the public record in connection with item p2 • ? ?- on 0 1I �los Priscilla A. Thompson// City Clerk If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE TITLE (X6) DATE STATE FORM 02119 LLKF11 If continuation sheet 1 of 1 Dcc r.51 79E af POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI, P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE i305) 416-1570 LICENSE YEAR OCT 1, 2004 THRU SEPT. 30, 2005 LICENSE FOR ACCOUNT NO. 22781, &_ -0011 8116 .9 LICENSE NO. ()Y71. 62-000 i ISSUED r.2:C T 0 i ';' cif)1. TOTAL FEE PAID NAME OF BUSINESS FAMILY IRA RD I NG: HOME I i-,-1(2 LOCATION ii3(30 SW 11 rER IS HEREBY LICENSED TO ENGAGE IN OR MANAGE `THE OPERATION OF: 12:0AP 1) X NSHOUSES c TO 10' FANILY POARDING HOME INC 1T:1,.DO SW 11 IERR ,M1 Aril FL 333..25 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the cily nor does it exempt the licensee lroin any other license or permits Mal may be required by law. This license does not constitute a certification that the licensee is qualified to engage i1 the business. profession or occupaticn specified hereon. The license indicates payment of the occupational license tax only. $40 OCO10517196 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT 1RANSFERABLE OR VALID AT ANOTHER ADDRESS UNLE3S APPROVED BY THE LICENSE SECTION, CITY OF MAMI. P.O. BOX 330708, MIAMI, FL 33233-0''08 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2003 THRU SEPT. 30, 2004 LICENSEFOR air a oA (4-0 1 Cs 40M1 IC ACCOUNT NO. .327846—Q01184qt° LICENSE NO. 097162_6000i ,)CT 10. NAME OF BUSINESS FAMILY BOARDING ?)4f: INC LOCATION 1800 SW 11 1 IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: ARDI NGH USES TO 10. TOTAL FEE PAID F AlqlY .f3OARN fl H5ME 1 .,?,.00 SW 11 T.E.P AMI FL 331 35 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city nor does it exempt the licensee nom any other license or permits that may be required by law. This license does not constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational license fax only. 11,40.C'D 200 0 0 X LICENSE FOR ACCOLIfq r NO. 37846-00/18465 LICENSE NO 0 ? 62_00,j1 !ssuED_____ NAME OF BUSINESS FAMILY riOARDING LocArRys 13:..1) SW 11 TER iS HEREkkjAiCENSED 10 IENGAdiVlsi OR MANAGE THE0FTtONOf - „ SOAR° INGHOJStS • OrAn 11 raer,nroegrawaaa.m.....inrocfammr.4,4,..... TO 110, POST HS LICENSE IN A CONSPICUOUS PLACE NOT TR,NSFEFRABLF OR "ALID AT ANOTHER ADDRESS :_,,NLES APPROVED BY THE LICENSE SECTION. CI OF MIAAI 130X 330708, folAmi FL 33233-070F, PHONE ".105 -116. 1510 LICEN:E YEAR OCT- 1, 2002 THFUJ SEPT 10, 2003 FAPILY BOARDING HOME INC _3tJ 2002 E INC T91/4. FEE RAI() F',MILY BOARDING HOME INC 1_33 SW 11 TEPP KIAMI,FL 33135 • THIS IS NOT A BILL DO NOT PAY tot pte:rne the le e0F.J.,e eie,,e, ,i• of Th. Cny ') i"-f':"..e,",r" le,e115'e (fterrei Seet e-'1. • •rf?..1 by J-1., NS I:terse , irrd, tite 1,cenSc'e .1f:U.' .". OW! ill iYOteSSIt)O I The hCP,se cayrnl.r, (+1 1S..* ftSIssOb if (3 ri) 3 8 Er a. 3 . • CL \ e OCC 1 051 7/9C ACCOUNT NO, LICENSE NO. NAME OF BUSINE .§,S, r LOCATION • " LICENSE FOR POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2001 THRU SEPT. 30, 2002 FAMILY OAf1G HOME INC 327E46-06118465 097162-0001 Isslim OCT IL, FAMILY 80A4DINu liumE INC SW 11 TER IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: ;-ARDINGHOUSE"Zi r TO ilo• TOTAL FEE PAID FAMILY 30ARDING HO,IE 14C T,274P miAmi FL ZY-6 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning laws of the city no does it exempt the licensee trom any other license or permits that may be required by law, 114s license does not constitute a certification that the licensee Is qualified to engage in the business, profession or occupation specified hereon, The license indicates payment of the occupational • gtertse tax only. 2002 VCC Oil 7.9 POST THIS LICENSE IN A CONSPICUOUS PLACE NOT TRANSFERABLE OR VALID AT ANOTHER ADDRESS UNLESS APPROVED BY THE LICENSE SECTION, CITY OF MIAMI. P.O. BOX 330708, MIAMI, FL 33233-0708 PHONE (305) 416-1570 LICENSE YEAR OCT. 1, 2000 THRU SEPT. 30, 2001 LICENSE FOR !--A,v,:LY iCADO ACCOUNT NO 7:4 46-3C11,3465 LICENSE NO 716 —0301 ISSUED NAME OF BUSINESS FAMILY 304R-)ING LOCATION 1 iI.; So 11 I EQ TO lo• IS HEREBY LICENSED TO ENGAGE IN OR MANAGE THE OPERATION OF: .:;•CT 13, 7.1 j TOTAL FEE PAID FAMILY ,FiGiliiDING HOME INC '4:4MI :FL 3 1 3 '3 THIS IS NOT A BILL DO NOT PAY This issuance of an occupational license does not permit the licensee to violate any zoning taws of the city nor does it exempt the licensee from any other license or permits that may be required by law. This license does not Constitute a certification that the licensee is qualified to engage in the business, profession or occupation specified hereon. The license indicates payment of the occupational lieen,se tax only. :a. .j • 20 (citu o-f „Miami CERTIFICATE OF USE Fi?E FAMILY 3,-,iAR• LNG HOME 1.300 SA 71 TVR MUM' FL 3313i—'i114 THIS IS NOT A BILL NOTICE: This: certificate is rron-Transierable. you relocate. sell the business, or change the type of business a new certificate must be obtained from Building and Zoning at 444 S.W. 2nd Avenue, 41h Floor, Phone: (305) 416-1129 DATE ISSUED: VALID FROM: •:!3 TOi 311D3 ACCOUNT NO: 327?,, SERVICE ADDRESS: 183j SQ 11 T. APPROVED USE: CU15—C..A. RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCAT ON AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFFCADO EN UN SITIO VISIBLE EN LA DIRECCION GEL COP.1EF?Cla NON—PROFIT — C.j. UOC 6065 (6/97) (4it of Alianti CERTIFICATE OF USE FIRE SAFETYPEMIT FAMILY ,7,GAREIFNG HOME le-Jc sw 11 TER MIAmi FL 33135-5114 THI IS NOT A BILL DATE ISSUED: VALID FROM: ACCOUNT NO: 32/ 1 '5 / 11/r:71/32 TO: 52746— 13?351 SERVICE ADDRESS: 1:2-SW 11 IFR APPROVED USE: CU15—E.3.P. NOA—PROFIF — C. RESTRICTIONS: NOTICE: This certificate is Non -Transferable. you relocate, sell the business, or change (he tyt. of business a new certificate must be obtainri. from Building and Zoning at 444 S W 21- Avenue. 4111EL:cr. Phone: (305) 416-1199 • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCAT ON AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCI (4itE Atiarni CERTIFICATE OF USE SAFf7TY PEMIT THIS IS NOT A DATE ISSUED: ? DOC #065 (8/97) NOTICE: This certificate is Non-Transferabl/. you relocate, sell the busineSs, er change the ty of business a new certificate must he obtain from Building and Zoning at 44.1 SVO. 2 - Avenue, 4th Floor. Plione2130.5) 416-1199 VALID FROM: / 1 I r.? 7 11: Z I31/ 2 ACCOUNTNO: 27 3, — !) 3 SERVICE ADDRESS: Sw 11 APPROVED pSE: CO'd-rt.:4?...O.NON*.P4Oftr RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO. DOC #065 (8/97) CO Cc-UR- of Atiami CERTIFICATE OF USE TQiF ciSFPTY oPPMTT c4YITI Y unmg iknn cid 11 rgi? Amt GI -331iS 11G 'HS I NOT A BILL DATE ISSUED: rt 2 n Inrt VALID FROM: 0/ ini /ni ACCOUNT NO: 2 7 g 6, 0, SERVICE ADDRESS: 1 AIM Su 11 Ti--P NOTICE: This carbficale is Non-Transferaolf. I you re.locate, sed the business. ot chartor,- Me. tyw of business a nev,,, certificate must be obtains( from Building and Z6ring -7-4t 444 SW 2rIc Avenue, 4th Floor. Phone: (305) 416-1199 TO:1 .7 / 1 ing 1 R 3 C 1 APPROVED USE: F_ —Pnt T RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DREG -CON DEL COMERCIO. Ccitu of Miami CERTIFICATE OF USE 3AFr:TY Y A1 11 TER FL 33135 14 THIS IS NOT A BILL DATE ISSUED: -13/17/ .1 VALID FROM: / f r 41 DOC 8065 (8/97) NOTICE: This certificate is Non -Transferable. you reloctafe, sell he business, or change Me type et business e new certificate must tya obtainer firm Building and Zoning r 444 S.W. 2.,t Avenue, •Ith Foror. Phone, (305) 416-1199 To1 1 I 1 ACCOUNT NU ').2'7 '!:* 31)4- 1 S 5.1 " SERVICE ADDRESS: ."-!.0..) SW 11 APPROVED USE: CU1S—C. . ) . RESTRICTIONS: • PLEASE DISPLAY THIS CERTIFICATE IN A CONSPICUOUS LOCATION AT OCCUPANCY ADDRESS. • FAVOR DE MOSTRAR ESTE CERTIFICADO EN UN SITIO VISIBLE EN LA DIRECCION DEL COMERCIO N --P ir — _ _ 1 DOC #065 (R/97) I I MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 14th FLOOR MIAMI, FL 33130 I I I I I I f I 2004 OCCUPATIONAL LICENSE TAX 2005 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2005 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 220594-6 BUSINESS NAME / LOCATION PINES 1800 SW 11 TERR 33135 MIAMI FIRST-CLASS U.S. POSTAGI PAID MIAMI, FL PERMIT NO. 2f THIS IS NOT A BILL -DO NOT PAY RENEWAL LICENSE NO. 094403-4 STATE #B11877 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE UCENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW, THIS IS NOT A CERTIFICATION OF THE LICENSEE'S QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/13/2004 30010000168 000150r p0 SEE OTHER SIDE MIAMI-DADECOU TAX' COLLEOTOR 1401W. FLAGLE r14tdJFLOOR.9:''. ;:MIAMI; FL33130 `3 BUNES$TIAME / LOCATION PINES 1800 SW 11 TERR 33135 MIAMI EMPLOYEE/S 5 DO NOT FORWARD PINES 1800 SW 11 TERR MIAMI FL 33135 t } +I 2iIi31 = If II IS I II I IIIIIii{! =3IIIIi}I FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 23 THIS IS 1%1(r A P 2. •'GO NOT F',',Y RIDNS>=Nb. 094403-4 STATE #B11877 OWNER FAMILY BOARDING HOME CORP Sec. Type of Business THIS Is ANOlCPA7IONALI STED LIVING FACILITY TAX ONLY. IT DOES NOT PERMIT THE UCENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY T A CERTIFICATIONS OR THE UCENSEES QUALIFICA- TION. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 08/08/2003 nn')onnnnnEo EMPLOYEES 5 DO NOT FORWARD PINES 1800 SW 11 TERR MIAMI FL 33135 t 11 11 11 22 1 1 . [ tY ♦e , „e ♦. 0 a- 0 CD co f1;;;;;;;-1,;, 40ftAtt.fr 220594-6 BUSNESS NAME / LOCATION PINES 1800 SW 11 TERR 33135 MIAMI A'WOr.,,;At5 *tb int `,AW, "1;5,90 -• 04, IFIRS. --ASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 23' RENEWAL LICENSE NO. 094403-4 STATE #B11877 OWNER FAMILY BOARDING HOME CLiRP Sec. Type of Business EMPLOYEES 213 ASSISTED LIVING FACILITY 5 THIS IS AN OCCUPATIONAL TAX ONLY. FT DOES NOT PERMIT THE LCENSEE TO VIOLATE AN D EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHR LICENSE OR PERMIT REQUIRED BY LAW. THIS S NOT A CERTIFICATIDtk OF THE LICENSEE'S OUALIFICA- 110N. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/26/2002 0210009(11201 000150.00 SEE OTHER SIDE DO NOT FORWARD PINES 1800 SW 11 TERR MIAMI FL 3 135 111111111111111111111 FilIII I I 1111111111111 11111 11 .. • ta 220594-6 C BUSINESS NAME/ LOCATION PINES 1800 SW 11 TERR 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. FT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REWIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE LICENSEE'S 7UALIFICA- TION. PAYMENT RECEVED MIAMI-DADE COJNTY TAX COLLECTOR: 09/26/2001 02020179001 ocolsolo FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 094403-4 STATE #611877 DO NOT FORWARD PINES 1800 SW 11 TERR MIAMI FL 33135 EMPLOYEES 5 IL tiiIiiL1I Z20.594-6 BUSINESS NAME / LOCATION PINES 1800 SW 11 TERR 33135 MIAMI OWNER FAMILY BOARDING HOME CORP Sec. Type of Business 213 ASSISTED LIVING FACILITY THIS IS AN OCCUPATIONAL TAX ONLY. IT DOES NOT PERMIT THE LICENSEE TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY 011 CITIES, NOR DOES IT EXEMPT THE LICENSEE FROM ANY OTHER LICENSE OR PERMIT REQUIRED BY LAW. THIS IS NOT A CERTI- FICATION OF THE LICENSEE'S OLIALIFICA- -TION PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/22/2000 050346001 000150gDO SEE OTHER SIDE FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL LICENSE NO. 094403-4 STATE 4811877 DO NOT FORWARD PINES 1800 SW 11 TEfR MIAMI FL 3313!; EMPLOYEES 5 Is ilis iv:111111:dd SI I:I; 11111! 111 E0,74Z094719 g°11se. 771,477i196-in 7,447t Submitted Into the Public record in connectio w'th item on I). Priscilla A. Tho ps n City Clerk FAMILY BOARDING HOME, INC is a Florida Corporation in charge of the operation of four Assisted Living Facilities license by the State of Florida to operated in Miami, Fl. SCOPE OF CARE The facility provides one or more personal care services to residents 400.402(6), F.S 400.402(17), F.S 400.407(3)(a), F.S Personal services means direct physical assistance with or supervision of activities of daily living and the self- administration of medication and other similar services. Personal services include, but are not limited to, individual assistance with or supervision of essential activities of daily living, as eating, bathing, grooming, dressing, toileting and ambulating; assistance with self administered medication. FACILITY RECORDS STANDARDS The facility is responsible for maintaining and having accessible all required facility records. 400.441(1)(e), S.S 58A-5.024, F.A.C. Facility must maintain an up-to-date resident admission and discharge log An up-to-date record of major incidents occurring within the last 2 years. The facility shall maintain liability insurance coverage in force at all the times The facility maintain a grievance procedure for receiving and responding to resident complaints and recommendations. The facility must have an annual fire inspection conducted by the local fire marshal or authority having jurisdiction. The facility shall provide documentation of a satisfactory sanitation inspection conducted annually by the County Health Department. The facility will maintain as public information all completed surveys, inspections and complaint investigation reports. The facility must report to the Agency, on a monthly basis, any and all liability claims filed against the facility. Submitted Into the public record in connecti• n ith item 'P-z • ys on �• oS Priscilla A. Thompson City Clerk RESIDENT RECORDS STANDARDS Resident records shall be maintained on the premises. 58A-5.024(3), F.A.0 Each resident must have a resident record in the facility which includes: • Admission Documents • Demographic data • Health data • Medical examinations • Health care provider's orders • Therapeutic diets • Weight records • Contracts = Medication Observation Record(MOR) • Health Care Surrogate designation • Do -Not resuscitate order • Guardianship documents • Advanced Directives, if completed ADMISSION CRITERIA STANDARDS Submitted into the public record in connection with item in, 2-> on r 5 Priscilla A. Tho pson City Clerk Each resident must be at least 18 years of age in order to meet residency criteria, 58A-5.0181(1)(a), F.A.0 Each resident must be free from signs and symptoms of any communicable disease which is likely to be transmitted to other residents or staff in order to meet residency criteria. 58A-5.0181(b), F.A.0 Each resident must be able to perform the activities of daily living, assistance if necessary in order to meet residency criteria. 58A-5.081(1)(c), F.A.0 supervision or Each resident must be able to transfer, with assistance if necessary in order to meet residency criteria. The assistance of more than one person is permitted. 58A-5.0181(1)(d), F.A.0 Each resident must be capable of taking his/her own medication with assistance from staff if necessary to meet residency criteria 58A-5.0181(1)(e)1; F.A.0 A resident shall not be a danger to self or others as deteiiiiined by a physician, or mental health practitioner licensed under chapters 490 or 491. 58A-5.0181(1)(g), F.A.0 A resident shall not required licensed professional mental health treatment on a 24-hour a day basis. 58A-5.0181(1)(h), F.A.0 A resident shall not be bedridden. 58A-5.0181(1)(i), F.A.0 RESIDENT CARE STANDARDS The facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 58A-5.0182 ,F.A.0 The facility provides 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. The facility will maintain a written record, updated as needed, of any significant changes in the resident's normal appearance or state of health, any illnesses which resulted in medical attention, major incidents, changes in method of medication administration, or other changes which resulted in the provision of additional services. The facility will provide an ongoing activities program. The program shall provide diversified individual and group activities in keeping with each resident's needs, abilities, and interests. Resident will be encourage to participate in social, recreational, educational and other activities within the facility and the community. The facility will maintain Cooperative Agreement with New Horizons Community Mental Health Center to provided residents with a Day Treatment Program on the facility premises. The facility shall as needed by each resident, assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. Submitted Into the public record in connection w't may- o item nThompson Priscilla A. City Clerk STAFFING STANDARDS The facility is under the supervision of an Administrator who is responsible for the operation and maintenance of the facility, including the management of all staff and the provision of adequate care to all residents. (See Resume attached as Exhibit A) 58A-5019(1),F.A.0 A Manager will be appoint in writing during periods of temporary absence of the Administrator, the manager shall complete the CORE training requirements within 3 months of becoming a manager, and shall attend update training for any portion of the CORE that has been revised as a result of new legislation, rule, amendment, or update material. 58A-5.0191(1)(b), F.A.0 58A-5.0191(1)(d), F.A.0 Each staff member's personnel record contains a copy of the original employment application with references. 400.4257(4), F.S 58A-5.024(2)(a) F.A.0 Personnel records should contain verification of freedom from communicable disease including tuberculosis. 400.4257(4), F.S 58A-5.024(2)(a), F.A.0 All facility employees must complete biennially, a continuing education course on HIV and AIDS. 400.4275(2), F.S Personnel records should contain documentation of current certification in an approved First Aid and CPR course. 400.4275(2) F.S Unlicensed persons who will be providing assistance with self-administered medications must receive a minimum of 4 hours of training prior to assuming this responsibility. 400.4256, F.S Staff who prepare or serve food must receive a minimum of 1 hour in-service training within 30 days of employment in safe food handling practices. 58A-5.0191(2)(e), F.A.0 Submitted Into the publi c record in connection w'th item pz- ?� on 05 Priscilla A. Tho p on City Clerk The Administrator or person designated by the administrator as responsible for the facility's food service and the day -to- day supervision of food service staff obtains, annually, a minimum of 2 hours continuing education in topics pertinent to nutrition and food service in an ALF. 400,452(6), F.S 58A-5.0191(6), F.A.0 The facility shall develop a written job description for each staff position and provide a copy of the job description to each staff member, 400.4275(4);F.S Personnel records should contain documentation of compliance with Level I background screening requirements. 400.4275(2),F.S Submitted Into the public record in connecti n item n22._.- on aC Priscilla A. Th mpson City Clerk Leonor Gonzalez 15304 SW 169 Lane Miami, Florida. 33187 Tel: (305) 235-6844 Cell: (305) 753-3933 Submitted Into the public record in connection ith item on or" Priscilla A. Th mpson City Clerk OBJECTIVE: A permanent position in Health Care setting with emphasis in Administration ,Counseling or Case Management services. PROFESSIONAL EXPERIENCE: April 1,2003 to Present- Administrator of Family Boarding Home Inc • • • Developed guidelines/policies for daily procedures. Responsible for monitoring and implementing current and new rules and regulations. Directly involved with the overall day to day operation of the facilities. August 2002 to Apri11,2003 Health Facility Evaluator H/Agency for Health Care Administration Survey ALF facilities to ensure compliance with State regulations according to Chapter 400 of Florida Statutes and Chapter 58A of Florida Administrative Code April 16,2002 to July,2002 Therapist / New Horizons Community Mental Health Center Currently working on Prior Authorizations for clients attending Rehab Day Treatment Program. May 1999 to January 25,2002 Administrator, Advanced Mental Addiction Rehabilitation Center • Developed guidelines/policies for daily procedures. • Responsible for monitoring and implementing current and new rules and regulations. • Directly involved with the overall day to day operation, including counseling and assessments. • Coordinating the timely implementation of corrective actions plans. • Clearly identified and make public services provided by the Agency and the geographic area in which these services are available. • Contracted local, state and national associations and participates in meetings and conventions. • Developed the After School Prevention and Intervention Program for " At Risk" Youth and the overall administration of the Program. Leonor Gonzalez 15304 SW 169 Lane Miami, FI 33187 August 1996 • • • • • • • Page 2 Submitted Into th record in connecti item ..r.k?'=o hdmpson Priscilla A. YCity Clerk to May 1999 Chief Executive Officer, Advanced Counseling Services. Implements governing body directives or policies. Implement Fiscal Management. Complies with applicable laws and regulations; Monitor quality and appropriateness of services and products; Overall Administration of Program. Coordination and liaison with appropriate affiliate departments and comittees; Represents the Program to other groups, agencies, and the general public, Keeps the governing body and staff informed of current organizational, community and industry trends. Develops policies and guidelines of operations; Assist in evaluation of community needs and plans programs and services to meet the identified needs. Keep current on local issues Submits formal written proposals to the Board of Directors for all new programs of services with complete cost/benefits analysis. Participates with other health, civic, educational and professional group as directed. Negotiates and enters into contractual agreement on behalf of the Program Responsible for maintaining sound fiscal management practices and the overall credit standing of the Program May 1990 to August 1996 CEO/ Administrator L & R Professional Nursing Services, Inc • Organized and Directs the Agency's ongoing functions. • Supervised total operation of the Agency • Oversees the development of standard and methods to measure Agency activities. • Participated in the review, analysis and appraisal of the effectiveness of the total Agency Program. • Provided for a continuing evaluation of the Program a. Evaluating service policies and function and recommending proposals for changes b. Evaluating the performance of the individuals in the Program in order to establish standards and the individual's professional development. c. The implementation of all utilization review activities. d. Coordinating the timely implementation of corrective action plans. • Employed qualified personnel and ensure adequate staff education and evaluation. • Meet the requirements of the Department of Health and Rehabilitative Services, and: a. Familiar with the Rules of the Department and maintain them in the Agency, b. Responsible for familiarizing the employees with the law and the rules of the Department and has copies of the rules available for their use. c. Responsible for the completion, keeping and submission of such reports and records as required by the Department. d. Designate a professional employee to his/her authorized representative in his/her absence. e. Maintained a current organizational chart to show lines of authority to the patient level. f. Maintained an office facility for the Agency which is large enough for efficient staff work, adequately equipped, and which provides for a safe working environment, meeting local ordinances and fire regulations. public n with Leonor Gonzalez 15304 Sw 169 Lane Miami, FI 33187 July 1987 to September 1988 Office Manager, Jose Valladares, MD. Page 3 Assisted in the developing of procedures and policies and the carrying of the procedure related to the practice. • Assisted with the liaison activities between employees and administration. • Maintain employee attendance records • Schedule and coordinated vacation time periods for clerical personnel. • Maintained all office equipment in working order, assures maintenance agreements on all products warranting. • Oversee the clerical personnel in their assignments and evaluates their performance annually. • Suggested further clerical staffing when the need arises. July 1985 to February 1987 Certified Nurse's Aide, South Shore Hospital • Assisted client's to achieve maximum self-reliance • Observed client's status, developmental characteristics, basic elements of body functions. • Recognize emergencies and appropriate response in an emergency. • Assisted in client's personal care techniques. • Reported any irregularity in client's condition. • Documented appropriate records. September 1984 to June 1987 Certified Nurse's Aide, St John Home Health Agency • • Assisted Clients in every way possible with their Activities of Daily Living, Reported immediately to the RN or administrator any significant change in the client's condition. Submitted Into the public record in connection with item Fs- ?" on -1 c Priscilla A. ThomClerk Leonor Gonzalez 15304 SW 169 Lane Miami, FI 33187 Page 4 EDUCATION: Certified Domestic Violence Counselor -III by American College of Forensic Counselors-03/03 Certified Cognitive Behavioral Therapist by National Board of Cognitive Behavioral Therapist - 03/03 Certified Clinical Criminal Justice Specialist by American College of Forensic Counselors - 03/02 Baccalaureate Addiction Counselor by American College of Forensic Counselors - 03/02 Assisted Living Facilities Core Training Program- Florida Department of Elder Affairs - 11/2001 Psychiatric Technology Guadalupe Vocational School - January 1997 Mental Health Technician - Health Education Services Inc - 03/1994 Medical Assistant - American Academy for Medical Assistant - 06/84 Nurse's Aide - Miami Dade Community College - 11/82 Three years of Medical School- Instituto Superior de Ciencias Medicas Havana- 1977 to 1980 Bachelors in Science and Letter - Pre Universitary Institute Antonio Guiteras Havana- 1977 Diversified involvement in Professional Seminars, Workshops and Conferences in the areas of Psychiatry, Medical and Substance Abuse / Addiction; including Aggression Control Techniques, AIDS, CPR, Domestic Violence and OSHA. Assets: Professional, Bilingual. Basic Computer knowledge References and Certificates : Available upon request. Submitted Into the public record in connection w ith item V 2 71^ on °s Priscilla A. Tho pson City Clerk Submitted Into the public record in connection with RESUME item p2. »'>, on A 5 Priscilla A. Tho pson RUBEN CORTEGUERA, P.A., C.A.P. City Clerk /5304 SW. 169 Lane Miami, Florida, 33187 Telephone #s: Home-(305) 235-6844; Cellular-(305) 753-3933; Beeper-(305) 713-2019 5�?'”//Sea/'a/;'y- rvii' 477'2( 26 sue. ; 9 a4.1.. 7W,d,,,,.,; 4. 33/if (305) 6S/3 -,2S 7/ 47,4 (.3o s) 6 Y'Y0 7/ -April 15, 2002 to Al '/ /5,'°0 3 NEW HORIZONS COMMUNITY MENTAL HEALTH CENTER, INC. 1313 NW 36 Street, Suite #400, Miami, Florida, 33142 Tele. (305) 759-5262; FAX (305) 756-5838 Position: Therapist. Responsible for facilitating individual, group and family sessions. Interact with other facility personnel to communicate information about client and needs for treatment. Assist in the establishment of a Treatment Plan which meets the individual needs of the client. Plan and implement discharge and after care arrangements. Supervisor: Jerry Rodriguez, Administrator -September 22, 1997 to April 12, 2002. ADVANCED MENTAL ADDICTION REHABILITATION CENTER (AMAR) 100 Beacom Boulevard, Miami, Florida, 33135. Phone (305) 541-3373, FAX (305) 541-8373. Position: Therapist. Initial Assessment; facilitate individual, group and family sessions; prevention and intervention sessions for adolescents and families at risk, responsible for the development and implementation of individualized Treatment Plan, discharge and after care follow up. Supervisor: Leonor Gonzalez, Administrator -January 22,1995 to September 16, 1997 DEPARTMENT OF JUSTICE, BUREAU OF PRISON, FEDERAL DETENTION CENTER-MIAMI, DEPARTMENT OF PSYCHOLOGY. 33 NE 4 Street, Miami, Florida, 33132-2111. Phone (305) 982-1422; FAX (305) 982-1413. Position: Drug Treatment Specialist (DTS) under the supervision of Dr. Victor E. Shoukry, Ph.D., Drug Abuse Program Coordinator from 03/14/96 to 09/16/97. Physician Assistant under the supervision of Dr. John E. Barnett, M.D., Medical/Clinical Director from 01/22/95 to 03/14/96. Page 1 of 3 RESUME EMPLOYMENT PAST HISTORY(Continuation) Submitted Into the public record in connection with item in- on Priscilla A. Thoftipson City Clerk -March 15, 1992 to January 21, 1995. SOUTH MIAMI HOSPITAL/ADDICTION TREATMENT PROGRAM 6200 SW 73th Street, South Miami, Florida, 33143. Phone (305) 662-8118; FAX (305) 662-5127. Position: Physician Assistant in a Detoxification Unit, under the supervision of Dr. Eric vanGinkel, M.D., and Lynn Hankes, M.D. -March 1989 to March 1992. UNIVERSITY OF MIAMI, DIVISION OF PROFESSIONAL DEVELOPMENT AND TRAINING, SCHOOL OF CONTINUING STUDIES. 800 Brunson Drive, ALLEN HALL, Coral Gables, Florida, 33124. Phone (305) 284-4451. Position: Faculty Member (Instructor ofPharmacology and the Diagnosis and Treatment of Related Disorders), under the supervision of Louise Seville, Ed.D., Program Director. -June 1982 to March 1992. MIAMI MENTAL HEALTH CENTER 3800 West Flagler Street, Miami, Florida, 33134. Phone (305) 774-3600 or 774-3300. Position: I worked in different positions as: Associated Director of Crisis Intervention Unit, Transitional Group Home Supervisor, Intake Coordinator, Human Services Counselor 1.11, Dual Diagnosis Counselor and Screening Crisis Intervention Counselor. I had different Supervisors as: Angel Garrido, M.D., Silvia Quintana, L.M.H.C., C.A.P., Lila Labarses, M.S.W. and Ileana Ruiz, Crisis Unit Director. -March 1981 to June 1982 NEW HORIZONS COMMUNITY MENTAL HEALTH CENTER 1469 NW 36 Street, Miami, florida, 33142. Phone (305) 635-0366. Position: Mental Health Technician and Residential Manager, under the supervision of Mercedes Sandoval, Ph.D. -February 1981 to March 1981 PUBLIC HEALTH TRUST OF JACKSON MEMORIAL HOSPITAL 1611 NW 12 Avenue, Miami, Florida, 33136. Phone (305) 549-7429. Position: Case Manager, under the supervision of Maria De La Rosa, M.S.W. and Mercedes Sandoval, Ph.D. Page 2 of 3 RESUME (Continuation) Submitted Into the public record in connection wi h item 1472 • ?? on P- OS -- Priscilla A. Thompson City Clerk EDUCATION: Licensed Physician Assistant with Prescribing Qualifications Certified Addiction Professional Internationally Certified Alcohol and Drug Counselor (ICRC/AODA National Association of Forensic Counselors/ Master Addiction Counselor Medical Doctor Graduated from University of Havana in 1979. CONTINUING Diveriified involvement in Professional Seminars, Workshops and EDUCATION: Conferences in the areas of Psychiatry, Substance Abuse/ Addiction, Administration, Aggression Control Techniques, AIDS, CPR, and a Refreshment Course for Physicians in Exile provided by the University of Miami, School of Medicine, Office of International Medical Education. Training in The Substance Abuse Subtle Screening Inventory (SASSI) Level I. I have been member of Quality Assurance Committee, Peer Review Comrnittee, Facilities Committee in different times in different centers. I also have participated in vaccination campaigns, food inspection, health control, sanitation and social work with needed people. I was Board Member for NATIONAL ART BY THE MENTALLY ILL (P.O.Box 350891, Miami, Florida, 33135-0891) from May 1989 to May 1994. President, Juan Martin Rodriguez, C.A.A.P. Page 3 of 3 AC1*, #1- STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTROL NO. 12/30/2003 PA 9100028 11529 The PHYSICIAN ASSISTANT . named below has met all requirements of the laws and rules of the state of Florida. Expiration Date: JANUARY 31, 2006 RUBEN CORTEGUERA 120 BEACOM BLVD. MIAMI, FL 33135 QUALIFICATION(S): PRESCRIBING #00002297 JEB BUSH J11W. AGWUNOBI, M.D., M.B.A. GOVERNOR SECRETARY DISPLAY IF REQUIRED BY LAW 0 (15- o Department of lder Affairs Assisted Living Facilities CERTIFICATION OF TIE COMPLETION OF THE CORE TRAINING PROGRAM Ruben Corteguera 266-95-5914 1.mm.d; 11/19/2001 CONTROL:000052323 Florida Certification Board 1715 S. Gadsden Street Tallahassee, Florida 32301 850-222-6314 www.ficertificationboard.org Member Ruben Corteguera Certilcatien Love!: CAP Certification 1<umbor: 894 Property of Florida Certification Board, Inc. v Submitted Into the public - record in connecti n with item ?Z. on Priscilla A. A. Thompson City Clerk