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Home My WebLink AboutItem O1 3986 3987 3988 3989 398: 3991 3992 3993 3994 3995 3996 3997 3998 3999 399: 39:1 39:2 39:3 39:4 39:5 39:6 RON DESANTIS GOVERNOR JASON WEIDA SECRETARY January 8, 2025 Lucy Cruz, AdministratorFile Number: 12962309 Tranquility Bay Adult Day CareCorpLicense Number: 9217 100980 Overseas HwyProvider Type: Adult Day Care Center KeyLargo, FL 33037-2560Application Number: 6708 RE: Facility located at 100980 Overseas Hwy, Key Largo Dear Administrator: The enclosed Adult Day Care Centerlicense with license number 9217and certificate number 4822isissued for the above provider effective June 18, 2024through June 17, 2026.The license is being issued for approval of therenewalapplication. The Agency no longer mails hard copies of licenses. Per Section 408.804(2), Florida Statutes, providers are required to print the license and post it in a conspicuous place readily visible to clients at the entrance of your facility. Review your certificate thoroughly to ensure that all information is correct and consistent with your records. If errors are noted, please contact the Assisted Living Unit. Please take a short customer satisfaction survey on our website at ahca.myflorida.com/survey/to let us know how we can serve you better. Additional licensure information can be found at http://ahca.myflorida.com/assistedliving. If you have any questions or need further assistance, please contact me at (850) 412-4476or email me at Sonja.Bradwell@ahca.myflorida.com. Sincerely, Sonja Bradwell SonjaBradwell Health Services & Facilities Consultant Assisted Living Unit Division of Health Care Policy and Oversight Agency for Healthcare Administration Facebook.com/AHCAFlorida 2727 Mahan Drive MS#30 X.com/AHCA_FL Tallahassee, FL 32308 AHCA.MyFlorida.com 39:8 39:9 39:: 3:11 EBUF!)NN0EE0ZZZZ* DFSUJGJDBUF!PG!MJBCJMJUZ!JOTVSBODF 1:01603136 UIJT!DFSUJGJDBUF!JT!JTTVFE!BT!B!NBUUFS!PG!JOGPSNBUJPO!POMZ!BOE!DPOGFST!OP!SJHIUT!VQPO!UIF!DFSUJGJDBUF!IPMEFS/!UIJT! DFSUJGJDBUF!EPFT!OPU!BGGJSNBUJWFMZ!PS!OFHBUJWFMZ!BNFOE-!FYUFOE!PS!BMUFS!UIF!DPWFSBHF!BGGPSEFE!CZ!UIF!QPMJDJFT! CFMPX/!UIJT!DFSUJGJDBUF!PG!JOTVSBODF!EPFT!OPU!DPOTUJUVUF!B!DPOUSBDU!CFUXFFO!UIF!JTTVJOH!JOTVSFS)T*-!BVUIPSJ\[FE! SFQSFTFOUBUJWF!PS!QSPEVDFS-!BOE!UIF!DFSUJGJDBUF!IPMEFS/ JNQPSUBOU;!Jg!uif!dfsujgjdbuf!ipmefs!jt!bo!BEEJUJPOBM!JOTVSFE-!uif!qpmjdz)jft*!nvtu!ibwf!BEEJUJPOBM!JOTVSFE!qspwjtjpot!ps!cf!foepstfe/! 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IJSFE!OPO.PXOFE! )Qfs!bddjefou*!%! 61-111! BVUPT!POMZBVUPT!POMZ % FBDI!PDDVSSFODF!%! VNCSFMMB!MJBC PDDVS BHHSFHBUF! %! FYDFTT!MJBC DMBJNT.NBEF % SFUFOUJPO!% EFE XPSLFST!DPNQFOTBUJPO! QFS!PUI.! Z0O TUBUVUFFS BOE!FNQMPZFST(!MJBCJMJUZ BOZQSPQSJFUPS0QBSUOFS0FYFDVUJWF! F/M/!FBDI!BDDJEFOU % O!0!B PGGJDFS0NFNCFSFYDMVEFE@ )Nboebupsz!jo!OI*! F/M/!EJTFBTF!.!FB!FNQMPZFF % Jg!zft-!eftdsjcf!voefs! F/M/!EJTFBTF!.!QPMJDZ!MJNJU % EFTDSJQUJPO!PG!PQFSBUJPOT!cfmpx Tff!BDPSE!212!gps!beejujpobm!dpwfsbhf!efubjmt/% ::::39382 ZO18019031361801903137 B EFTDSJQUJPO!PG!PQFSBUJPOT!0!MPDBUJPOT!0!WFIJDMFT!)BDPSE!212-!Beejujpobm!Sfnbslt!Tdifevmf-!nbz!cf!buubdife!jg!npsf!tqbdf!jt!sfrvjsfe* DFSUJGJDBUF!IPMEFSDBODFMMBUJPO TIPVME!BOZ!PG!UIF!BCPWF!EFTDSJCFE!QPMJDJFT!CF!DBODFMMFE!CFGPSF UIF!FYQJSBUJPO!EBUF!UIFSFPG-!OPUJDF!XJMM!CF!EFMJWFSFE!JO NPOSPF!DPVOUZ!CPDD! BDDPSEBODF!XJUI!UIF!QPMJDZ!QSPWJTJPOT/ 2211!TJNPOUPO!TUSFFU! LFZ!XFTU-!GM!44151 BVUIPSJ\[FE!SFQSFTFOUBUJWF ª!2:99.3126!BDPSE!DPSQPSBUJPO/!Bmm!sjhiut!sftfswfe/ 3:12 BDPSE!36!)3127014*!Uif!BDPSE!obnf!boe!mphp!bsf!sfhjtufsfe!nbslt!pg!BDPSE BHFODZ!DVTUPNFS!JE; MPD!$; Qbhf!pg! 2!2 BEEJUJPOBMSFNBSLTTDIFEVMF BHFODZOBNFE!JOTVSFE TfcboebJotvsbodfUSBORVJMJUZCBZBEVMUEBZDBSF-DPSQ/ 211:91!Pwfstfbt!Ixz! QPMJDZ!OVNCFS Lfz!Mbshp-!GM!44148 ::::39382 DBSSJFSOBJDDPEF FGGFDUJWF!EBUF;! QsphsfttjwfFyqsfttJotvsbodfDpnqboz212:41801903136 BEEJUJPOBM!SFNBSLT UIJT!BEEJUJPOBM!SFNBSLT!GPSN!JT!B!TDIFEVMF!UP!BDPSE!GPSN- 36Dfsujgjdbuf!pg!Mjbcjmjuz!Jotvsbodf GPSN!OVNCFS;GPSN!UJUMF; Beejujpobm!Dpwfsbhft Jotvsbodf!dpwfsbhf)t*!Mjnjut Qfstpobm!Jokvsz!Qspufdujpo!%21-111!x0%1!Efe!.!Obnfe!Jotvsfe!Pomz Eftdsjqujpo!pg!Mpdbujpo0Wfijdmft0Tqfdjbm!Jufnt Tdifevmfe!bvupt!pomz 3128!GPSE!USBOTJU!2GCBY3DN1ILC18319 Dpnqsfifotjwf!%2-111!Efe Dpmmjtjpo!%2-111!Efe Beejujpobm!Jogpsnbujpo Dfsujgjdbuf!ipmefs!jt!mjtufe!bt!bo!Beejujpobm!Jotvsfe/ BDPSE!212!)3119012*!ª!3119!BDPSE!DPSQPSBUJPO/!Bmm!sjhiut!sftfswfe/! 3:13 Uif!BDPSE!obnf!boe!mphp!bsf!sfhjtufsfe!nbslt!pg!BDPSE DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/05/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER AILYN BEDOYA NAME: FAX PHONE Sebanda Insurance Corp(305)665-0016(888)979-8772 (A/C, No): (A/C, No, Ext): E-MAIL 6401 Bird Roadinfo@sebandainsurance.com ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # MIAMIFL33155-4825NAUTILUS INS CO17370 INSURER A : INSURED PROGRESSIVE EXPRESS INS CO10193 INSURER B : TRANQUILITY BAY ADULT DAY CARE CORP INSURER C : 100980 Overseas Hwy INSURER D : INSURER E : Key LargoFL33037 INSURER F : COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR INSRPOLICY EFFPOLICY EXP TYPE OF INSURANCELIMITS POLICY NUMBER LTR(MM/DD/YYYY)(MM/DD/YYYY) INSDWVD COMMERCIAL GENERAL LIABILITY 1 000 000 EACH OCCURRENCE$ DAMAGE TO RENTED 100 000 CLAIMS-MADEOCCUR$ PREMISES (Ea occurrence) 5 000 MED EXP (Any one person)$ AYVIAMU-O10/18/202410/18/20251 000 000 PERSONAL & ADV INJURY$ 2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ PRO- INCLUDED POLICYLOCPRODUCTS - COMP/OP AGG$ JECT $ BI/PD DEDC500 OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY$ 300 000 (Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNEDSCHEDULED BODILY INJURY (Per accident)$ BY0418836510/19/202410/19/2025 AUTOS ONLYAUTOS NON-OWNED HIREDPROPERTY DAMAGE $ (Per accident) AUTOS ONLYAUTOS ONLY $ P.I.P10 000 UMBRELLA LIAB EACH OCCURRENCE$ OCCUR EXCESS LIAB CLAIMS-MADEAGGREGATE$ $ DEDRETENTION$ PEROTH- WORKERS COMPENSATION STATUTEER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT$ N / A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below Each Event:100 000 AVIAMU-O10/18/202410/18/2025Aggregate300 000 Sexual Abuse Or Molestation DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Scheduled Vehicles 2019 FORD TRANSIT CONNECT NM0GE9G23K1424844 MONROE COUNTY IS NAMED AS AN ADDITIONAL INSURED IN RESPECTS TO THE GENERAL LIABILITY AND AUTOMOBILE LIABILITY POLICIES. CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOCC 1100 SIMONTON STREET AUTHORIZED REPRESENTATIVE KEY WESTFL33040 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD 3:14 REQUESTFOR WAIVER OFINSURANCEREQUIREMENTS Itis requestedthattheinsurancerequirements,asspecifiedinthe ScheduleofInsurance Requirements,bewaivedormodifiedonthefollowingcontract. UsborvjmjuzCbzBevmuEbzDbsfDpsq)LfzMbshp* Contractor/Vendor: TpdjbmTfswjdftJo.IpnfQsphsbn ProjectorService: Contractor/Vendor 211:91PwfstfbtIxz Address&Phone#: LfzMbshp-GM44148 qspwjefgbdjmjuz.cbtfesftqjufboebevmuebzdbsftfswjdftupfmefsmzboeejtbcmfesftjefout GeneralScopeofWork: Dpousbdupsdmbjntfmjhjcjmjuzgpsxpslfs(tdpnqfotbujpo ReasonforWaiveror fyfnqujpo/ Modification: PoliciesWaiveror Xpslfs(tDpnqfotbujpo/XbjwfsdpoujohfoupoTubuf Modificationwillapplyto: bqqspwbmpgbuubdifebqqmjdbujpogpsfyfnqujpo SignatureofContractor/Vendor: Date:ApprovedNotApproved 5 Ejhjubmmz!tjhofe!cz!Hbfmbo!Q!Kpoft! Hbfmbo!Q!Kpoft Ebuf;!3136/1:/21!27;53;3:!.15(11( RiskManagementSignature:_ Date: CountyAdministratorappeal: Approved:NotApproved: Date: BoardofCountyCommissionersappeal: Approved:NotApproved: MeetingDate: 3:15 NOTICE OF ELECTION TO BE EXEMPT If this application contains incomplete or inaccurate information, it may cause a delay in the issuance of your exemption. An officer electing an exemption under Chapter 440, Florida Statutes, is not entitled to benefits under this chapter. Section1: APPLICANT INFORMATION First & Last Name:LORENAMSANTANA VALID State Driver's License Number:State:FLFlorida ID Number: S535533976790 Driver's License Expiration Date:5/19/2031 Date of Birth: 5/19/1997 Email Address:TRANQUILITYBAYADULTDAYCAREKEYL@GMAIL.COM Section2: NON-CONSTRUCTION INDUSTRY APPLICANT (NO FEE REQUIRED) Officer of a Corporation Section 3: This section should be completed with information specific to your corporation or to the limited liability company in which you are a member. The name of the corporation or limited liability company listed on this application MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations. Name of Corporation or LLC:TRANQUILITY BAY ADULT DAY CARE, CORP.FEIN:454896661 Business Name (DBA): Phone:7865725498 Applicant's Address of Record: 100980 OVERSEAS HIGHWAY City:KEY LARGOState:FLZip33037County:MONROE Section4: The corporation of which you are an officer or limited liability company of which you are a member must be registered and in ACTIVE status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number on file with the Florida Division of Corporations. P12000029294 Section 5: THIS SECTION IS NOT APPLICABLE TO MY BUSINESS. DBPR License Number: Additional DBPR License Number: 3:16 Section 6: If you have submitted an electronic payment for this application, the transaction confirmation number is listed in the following space: Confirmation Number:Application Number:E02208109 Section 7:N/A Are you affiliated with any corporation or limited liability company other than the corporation or limited liability company to which this application applies? Section 8: CONSTRUCTION INDUSTRY AND NON-CONSTRUCTION INDUSTRY LLC MEMBERS ONLY To be eligible for a construction industry exemption or a non-construction limited liability company exemption, an applicant must have the required ownership of the corporation or limited liability company. Section 9: I certify that any employees of the corporation or members of the limited liability company listed in Section 3 are covered by workers' compensation insurance. Please identify the workers' compensation insurance carrier that covers any non-exempt employees. Carrier Name:My business does not have any non-exempt employees; or, my business is not required to obtain workers' compensation. Section 10: FRAUD NOTICE Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, A. insurance company or any other person, files a Notice of Election to be Exempt containing any false or misleading information is guilty of a felony of the third degree. B. Attestation of applicant By providing my name below, I attest that I have read, understand and acknowledge the foregoing notice. C.I acknowledge that this Notice of Election to be Exempt does not exceed limits for corporate officers, including any affiliated corporations as provided in Section 440.02, Florida Statutes. D.I certify I reviewed and understand the workerscompensation coverage and compliance tutorial developed by the department. First Name:Last Name:Driver's License Number OR Identification Card Number: LORENASANTANAS535533976790 Note: The Division has 30 days to review your application to determine if it meets the eligibility requirements for the issuance of an exemption. The Division will either issue a Certificate of Election to be Exempt or notify you that your application is incomplete. The Division reviews and processes exemption applications in the order they are received. Exemption information is reflected on the Exemption Search database the day following the issuance of the exemption. 3:17 3:18 3:19 3:1: 3:21 3:22 3:23 3:24 3:25 3:26 3:27 3:28 3:29 3:2: 3:31 3:32 3:33 3:34 3:35 3:36 3:37 3:38 3:39 3:3: 3:41 3:42 3:43 3:44 3:45 3:46 3:47 3:48 3:49 3:4: 3:51 3:52 3:53 3:54 3:55