STATEOF FLORIDA '

DEPARTMENTOF CHILDRENANDFAMILIES E)ilIIBITA

INTHEMATTEROF CertifiedMail .
The Revocation
-License Of Returnreceiptreqirested
As A Child
PlacingAgencyln
TheStateOf Florida
TediBearAdoptions,Inc.
1415Atlantic
Blvd.
NeptuneBeach,FL 32266
AMENDED ADMINISTRATIVE COMPLAINT
YOUARE HEREBYNOTIFIED thatthe Stateof Florida,Department
of Children
'Department")
and Families,(hereinafter intendsto revokeyour licenseas a
agency,As groundsfor the revocation,
child-placing the Depaftmentstatesas
follows:
1. The Departmenthas authorityto take this action pursuantto section
409.175(8XbX2),
FlofidaStatutes.
2. The Respondent, 'Respondent"
Tedi BearAdoptions,Inc.,(hereinafter or
TBA") is a Floridanon-profitcorporation,whose registeredagent is Tedi
Hedstrom.
3. The Respondentis licensedas a child-placingagencyunderChapter
409.175,FloridaStatutes,andRules65C-15,FloridaAdministrative
Code.
4. On October2 and 3, 2002, after receiptand investigation of multiple
complaints fromcunentandformerclientsandformeremployees, andpursuant
to Rule65C-15.004, Code,an unannounced
FloridaAdministrative on-sitevisit
was made to this Respondentby LicensingSpecialistTaffi/ Compainand
Operational ReviewSpecialistCarol Hutcheson.As a resultof this visit the
followingviolations code were
of FloridaStatutesandthe FloridaAdministrative
discovered.

A, CompainReviow

5. As of the dates of our complaintinvestigation,

TBA did not have the
requiredauditsfor the yearsendedJune30, 2001or June90, 2002. This is a
violationof Rule65C-15.010(3), Code.
FloridaAdministrative
6. ProgramDirectorsworkingfor this Respondenthave been located
residingin other states. ProgramDirectorsfor this Respondentperfonn
caseworkfunctionssuchas: recruilingadoptiveclienis;providing the clientwith
a!l paperwork (otherthanthe homestudy) for INS approval; assisting clientswith
all papeMorkneededto completethe dossierto submit to the country;
answering queslions;andcommunicating
all country-speciflc withthe facilitators
regardingreferrals,traveldatesandforeigncountryadoptionprocesses.These
individualsalsomaintainthe originalconfidentialclientfiles in theirhomesuntil
the familyis backin the UnitedStates wiih theiradoptedchild,at whichiime,
theyreportedly returntheserecordsto TBA.
Rule65C-15.003(4), Code,statesthat:
FloridaAdmiriistrative
"a licensedagencymayoperatea branchor satelliteoffices
withoutseparatelicensesfor thoseoffices.However,each
branchor satelliteoffic€mustbe disclosedin the application
for licenseby submittinga copyof HRSForm5135for each
office.lf ihe agencyopensa branchor satelliteofflceduring
the licensed term,the agencyshallfileHRSForm5135not
lessthan10daysprjorto the openingof the newoffice.".
Th€ oul-of-state programdirectorswere conducting TBA businessout of their
homes. Suchooerationsconstitutea branchor satelliteofficefor TBA.TBA'S
for licensuredid not reportit hadihesesatelliteofticesas required.
application
Assuch,thisis a violationof Rule65C-15.003(4),FloridaAdministrativecode-

7. Educational was notavailablein anyofthe ProgramDirectors'

verification
personnel filesreviewed. This is a violationof Rule65C-15.016(1), Florida
AdministrativeCode,whichrequiresthatthe agencyshallhaveavailable on site
theeducational qualifications to veriv thattheymeetthe standards
of ernployees
sotforthin 65C-'15.017."
8. Collegedegreeswerenot in thepersonnel filesof formeremployees
Amy
Bleich,Wendy Landessor DeidraDudley. This is a violationof Rule 65C-
15.016(2),
FloridaAdministrative Code,whichrequires'the agencyto havea
personnel
filewitha copyof a diplomaor degreefor eachemPloyee.'
9. Rule65c-15.016(2),
Florida cod6,requirss:
Administrative
the agencyto have a peKionnelfile for each employee
which would include the following: application for
employment:verificationof screeningrequirements being
met:employees' dalesand reasons
startingandtermination
for termination;annual performanc€ evaluationsand any
actionstaken;copy of diplomaor degree;and
disciplinary
trainingrecotdandconferences attended."

Five of the personnelfiles revieweddid not containrequiredverificationof

screeningrequirements and six of the personnelflles revieweddid not contain
adequale verification
thatemployees weremeetingtrainingrequirements.
. Regarding
vedfication
of screeningrequirements:

As part of the re-licensure

process,Tedi Hedstromexecuteda Background
"have been
ScreeningAffidavitaffirmingthat dll personnelof this agency
fingerprinted
andare in compliancewiththe backgroundscreeningrequirements
ofsection409.175, F.S.'
'lwlhenevera background
Section435.01, Florida Statules providesthat
screening
for employmentor a background securitycheckis requiredby lawfor
employment,unless o wise providedby law, the prov ns of this chapter
shallapply."

KellyFrasier- No proofof fingerprint

checkin employeefile.Thisis a violation
of Rule 65C-15.016(2),FloridaAdministrative Code, and is con$aryto the
Background ScreeningAffidavitcontained file.
in the licensure

ShannonStorie- No proofof fingerprint checkin the employeefile.This is a

FloridaAdministrative
violationof Rule65C-15.016(2), code' and is contraryto
ihe Background Affidavitcontained
Screening file
in the licensure
- Affidavitof GoodMoralCharacter
WendyLandess notsignedby employee.

VickieBrown(Boyd)- The FPSScheckverification was not in employee'stile

Florida
This is a violationof Rule65C-'15.016(2), AdministrativeCode, and is
contrary to lhe BackgroundScreening in thelicensure
Affidavitcontained file.

r Regarding of trainingand conferences

verification (Rule65C-
requirements
15.018(2),FloridaAdministrative code, requires15 hours in-service
of
training
annually):
Tedi Hedstromadmittedto fabricatingcerlificatesof attendancefor TBA
employees.Accordingto a former employee,TBA would create training
for employeeswho did not actuallyattendthe training,and the
certificates
were then includedin the employee'sfile just priorto ils annual
certificates
licensurerenewalaudit,to makeappearthatTBAwas in complianceThis is a
violationof Rule 65C-15.018,FloridaAdministrative Code. Also, knowingly
providingfalse informationconstitutesa violationof Section63'212(2)(a)1.'
offense-
FloridaStalutes,andis a criminalandadministrative
' Otherviolations
areas follows:
. DonnieHedstrom - Signedas supervisor on hisowntraininglogon"TBAApril27
and 29,2002.Therewas alsoan entryfor a February19, 2002 In-
withno description
Service"- of the contentof the trainingthatwas provided.
Documentationfor training notbeenrecorded
has thisyear.Thisis a violation
of Rules65C-15.016(2) and65C15.018(2), Florida Code.
Administrative

.' VickieBrown,Directorof SocialWork- Onlyhad a lotal of 9 traininghours

logged,noneof whichcouldbe verifiedandwhichis lessthanthe required15
FloridaAdministrative
hoursandis a violationRule65C-15.018(2), Code.

r Amy Bleich- Her performance evaluationcompletedby Tedi Hedslrom,

listedher positionas "Client
SupporuProgram Director."She had a totalof
59 hours of training per her training log. However,lhere was no
documentation to supportthe log entries.This is a violalionof Rule 65C-
 15.016(2),
Florida,l rinistrative
Code,and a violatiol dle 65C-15.018(2),
FloridaAdministEtiveCode. I

Trish Mccrary - There was an entry dated for only one day, August 21,
2001, which shows "ln-Service,48 hours". There are no documentsol
trainingmaterialsto ve ry the length of training,what topics the employee
was trainedon or that this trainingoccurred.This is a violationof Rules65C-
'15.016(2)
and65C-15.018(2), FloridaAdministrativeCode.

DeidraDudley-

> TBAs employeefile for Ms. Dudleycontainedno employeeapplication.

Thisis a violation FloridaAdministrative
of Rule65C-15.016(2), Code.

> Withoutdocumentationof employmentof Ms. Dudleyby TBA, an agency

relationshipcannot be establishedthat would authorizeMs. Dudleyto
have possessionof these confidentialrecords. This is a violationof
section 63.'162(2), Florida Statutes and Rule 65C-15.013, Florida
AdministrativeCode.

> Thereareno trainingdocuments

in thisemployee's
file.Thisis a violation
of Rules65C-15.016(2) Florida
and65C-15.018(2), Administrative Code.
> There were no recordsof backgroundchecks performed.This is a
violationof section435.05,FloridaStatutes,and Rula 65G15.016(2),
FloridaAdministrative Coda,andis contraryto the Background
Screening
Affidavitcontainedin the licensure
file.
10. Confidential adoptionrecordsare maintainedout of state by Program
Directors,
andTBAmaintainsnot evena copyof theserecords.Onlyafterthe
familyreturnsto the UnitedStateswith the adoptedchildare the originalfiles
mailedto TBAfromthe out-of-state
directors.Failingto maintainfileson siteis a
violationof Rules 65C-15.031,65C-15.032and 65C-15.034,Florida
Administrative
Code.
11. As of October 15. 2002. TBA'Swebsitelocatedon the Internetat
did not includethe Respondenta.Florida
http:/fu/ww.tedibearadoptions.org/
Licensenumberof the agency,which is a violationof Seclion63.212(1)(9),
FloridaStatutesandRule65C-15.002(9), Code.
FloridaAdministrative
12. Specificauthorityfor Rule65C-15.0!7(1), FloridaAdministrative
Code,is
contained in ChaDters63 and409, FloridaStatutes.This Rulerequires that the
agencydirectorshallhavea mastedsdegreein socialworkor a relatedareaof
studyfroman accredited andat leasttwoyears'experience
collegeor university
in humanservlcesor childwelfareprograms. A bachelor's degreein socialwork
or a relatedareaof studyfroman accredited andfouryears
collegeor university
of experience in humanservicesor childwelfareprograms may be substituted.
A
doctorate degreein sociatworkor a relatedareaof studymaybe substituted for
one year of therequiredexperjence."
Ms. Hedstrom,Executi Directorof TBA, falsifiedher en )ymentapplicaiiori
by indicatingshe hasra BA,/BSdegreewith a majorin SocialWorllEducation:'
However,her resumeshowsshe has a BA with a majorin Education from the
University
of NorthFlorida,'1987 anda minorin SocialWork from FloridaState.
University. Whenquestioned abouther applicationshowinga majorin social
workandherresumeshowinga minorin it, she admitted thatshedoesnot have
a degreein socialwork and that thoughshe attendedclasses,she did not
graduatefrom FloridaState Universiv. The reviewerverified that Tedi
Hedstrom's Bacheloisdegreeis in Educationonly.Knowinglyprovidingfalse
information a violationof Section63.212(2)(a11.,
constitutes whichis a criminal
andadministrativeoffense.
Accordingto Pam Graham,MSW,the AssistantDeanof the FSU Schoolof
SocialWork, teachingexperienceis not consideredequal to social work
experience.Ms. Hedstromdoes not possessthe educationalcredentialsfor
agency.ThisviolatesRule65C-
beingan executivedirectorof a child-placing
15.017(1), Florida
Administrative
Code.
13. The Directorof SocialWork, Vickie Brown,has a Mastedsdegreein
Education(SpecialEd.)from the Universityof NorthFlorida,1984. Her prior
workexperience was as a taacherfor the DuvalCountySchoolSystem,1997-
2000andshealsoworkedfor the Okeechobee SchoolBoardfrom1991till 1997.
Accordingto Pam Graham,MSW,the AssistantDeanof the FSU Schoolof
SocialWork, teachingoxperienceis not consideredequal to social work
experience.As such,Ms. Browndoesnot havethe requiredcredentials to hold
the position
of Directorof SocialWork. Thisis a violationof Rule65C-15.017(2),
FloridaAdministrative
Code.
14. DonnieHedstrom is a formeradoptioncaseworker for TBA.Mr. Hedstrom
admits he has conducted adoption home studies and post-placement
visits/reports. However,Mr. Hedstrompossessesa Bachelordegree in
Government. He has no socialwork experience eitherin schoolingor previous
employment.His previous employmenthistorywas as an owner of a car
dealershipin Jacksonville from 1986 until he beganworkingfor TBA. Mr.
Hadstromis not qualifiedto perform home studies and post-placement
supervisionvisitsas a socialworker. Thisis a violationof Rule65C-15-017(3),
FloridaAdministrativeCode.

15. Requirements of theadoptivehomestudydoneby DonnieHedstrom on

Rs wereabsentand/orinadequaie.Deficiencies includedno documentation of
discussingchildcare planswith the applicant,who was a single-parent who
worksoutsidethe home;no documentation of discussingattitudesandfeelings
of the applicani'sfamily,the extendedmembersor significantothers,toward
adoptivechildren;no documentation of addressingthe applicant'splan for
djscussingthe adoptionwith the child;the adoptivechild'sattitudetowardthe
birth parentswas not addressed;there was no assessmentof the adoptive
parents'capacitiesto give and/or receive affection;and there was no
assessmentof the adoptiveparents'child caringskills. Further,there was
inadequate detailor examptesof the applicantsabilityto copewith problems.
The overall quality of the home study reviewedwas poor and did not
substantiallycomply l the requirementsof Rule C-15.028,Florida
Admlnistrative
Code.

16. Patti Mcclaughlin- Had no.collegedegree and servedas program

directorfor Chinaand Hong Kong. This violatesRule 65C-15.017(3),
Florida
Administrative
Code:

17. CheryaBor - Had no collegedegrce and servedas ProgramDirectorfor

FloridaAdministrative
Kazakhstanand Russia.This violalesRule 65C-15.0'17(3),
Code.

18. A requirementfor TBA'Srelicensurewas providinga correctiveactionplan

for deficienciesnotedduringthe June 6, 2002 relicensuremonitoring,(see June
11, 2002 correspondence from Linda Rosenthalto Tedi Hedstromaftachedas
Exhibit "A", requesting a performance improvement plan). The attached
correctiveactionplan submittedby TBA on June 21, 2002 (attachedas Exhibit
'B'indicated that the deficiencieshad been resolved. However,the deficiencies
alteged in paragraphsfour through sixteen of this AdministrativeComplaint,
demonstratethat TBA has failedto substantiallycomplywith its correctiveaction
plan. Additionally,a correctiveaction plan was requiredfor relicensingin 1999
"D' respectlvely)and many of the
and in 2000, (attachedas Exhibit 'c" and
deficienciesnotedat thosetimesare still continuingto occur.

B. HutchosonRoview

19. In additionto reviewingemployeafiles and otheragencydocumentationin

orderto determineif licensingrequirementswere beingmet, also reviewedwere
11 fites of familiesinvolvedwith TBA for internationaladoptionand two files of
familiesparticipatingin domeslicadoptions. The followingdeiailsvariousother
violationsof FloridaSlatutesand the Flolida AdministrativeCode discoveredin
these reviews. Due to confidentialityand'exemptionrequirements,initialsshall
refer to the adoption applicants and adoptive parents. A list with
corrEsponding names shall be served on tho Respondentalong with this
Administrative ComplainL

The As File
The A's allegeTBA failedto protectlheir confidentiality. Releasingan adoptiva
parents identitywithouttheir written consentis a violationof section63.162(4)'
FloridaStatutes,and Rule65C-013,FloridaAdministrative Code
The L's File
This file indicatedthat the adoptivefamily arrivedback in the UnitedStateswith
childrenfrom Moldovain January2001. There were no post plac€mentreports
in the file. Failingto conductpost placementreviewsfor these adoptionsis a
violationof section63.125(5), FloridaStatutes,and Rule65C-16.010(4), Florida
Administrative Code.

The S's File

After reviewingthis file it was impossibleto determinewho actuallyplacedthe
childin the home. Thisis a violationof 65C-15.030('1Xd),FloridaAdministiative
Code.

The R's File

This file containsa letterdated November15, 2001 from Tedi Bear Adoptions
stating the requirementsfor post placement visits. However, the record
containedno post placementreports.This is a violationof Section63.125(5)'
FloridaStatutes. and Rule65C-16.010(4), Code.
FloridaAdministrative

The B's Filo

This fite indicatedthat post placement reports were due in April, June and
September. However,the Septsmber report was not in the file. This is a
violationof Seclion63.125(5),FloridaStatutes,and Rule65C-16.010(4)'Florida
Administrative Code.

The B's File

This file did not contain any post placementreports. When questioned,the
ExecutiveDirectorfor TBA telephonedthe adoptivemotherto ask who had done
'the
Dostolacementwork. The adoptivemother reported'thatDonaldHedstrom
conductadthe visits. The ExecutiveDirectorfor TBA was only ableto locateone
of the three requiredreports. However,this reportwas completedfive months
'aftdr
the established due date.This,isa violationof Section63.125(5)'Florida
Statutes,and Rule65C-16.010(4), Code.
FloridaAdministrative

TheKandHFiles
Upori arrivaiat ttte agencythe ExecutiveDirectorfor TBA was given a list of
ctientfiles that neededto be reviewed.The K and H fileswere both requestedat
' that time. the ExecutiveDireciorfor TBA siated that neitherthe K's nor the H's
were clientsof TBA. I asked her to describeTBAS relationshipto the families.
She statedthat she had no relationshipwiih these families,.andexplainedthai
they were clientsof a differentagency,New Arrivals. She.statedthat TBA and
New Arrivals shared the same facilitator in Vietnam' and she sometimes
receivedmailforthese familiesbv mistake. She statedthat her only involvement'
was to foMard this mail to New Anivals adoptionagency. I specificallyasked
her if she had any clieniflles or had receivedany moneyfrom eitherfamily. She
"no."
statedthat the answerto bothquestionswas

On the secondday of the reviewa staff memberapproachedthe reviewersand

askedfor the H file, indicatingthat she had some informationto add to the file.
The reviewersstaiedthat the ExeculiveDirectorfor TBA informedus that there
alsostatedthat,if thiswasincorrect,
wasno fileforthisfamily.Thereviewers
the iile should be pro ,ed for review. A file was subs lently producedfor
both families. Thus, contrary to whai ihe reviewers had previouslybeen
informed,tiles were being maintainedon these families,for reasonsthat could
not fully be explainedby TBA.

The informationin these llles consistedof copiesof informationfrom the New

Anivals agency. lf TBA is not the child-placingagenciesfor these families,it
should not be in possessionof their confidentialadoPtionrecords. Having
informationregardingthese non-clientfamiliesis a violationof 63.162(4),Florida ,"
Statutes.and 65C.013.FloridaAdministrativeCode.

Tedi Hedstromcouldnot explainwhatthe relationshipis betweenTBA and these

families. However,when questioned about this relationship,the Executive
Directorfor TBA indicatedthat she did collecta $2000networkingfee from these
families. Section63.097, FloridaStatutesoutlinethe fees which an adoption
entity may access against an adoptiveparent. There is no provisionin this
"networking"fee. Accotdingly,
statute that allows the assessment of a
assessmentof such a fee is a violationof section63.097,FloridaStatutes,and
Rule65C-15.010,FloridaAdministrativeCode.

C. Complaints by Adoptivo Paronts, Current and Former Clionts and

Former Employoos

20. JM is an adoptive parent who alleges that TBA offered her adopted
Vietnamesedaughter to another person for adoption,This is a violation of
section63.212(2Xa)1.,
FloddaStatutes.
-ProjectFaith,"was
21. JM allegesthat a websiteowned by TBA known as
usedto solicitdonationsusingfabricatedstoriesabout childrenbeingabusedor
and Rule65C-15.0'13,
FloridaStatutes,
sick. Thisis a violationof 63.212(2Xa)1.,
FloridaAdministrative Code.

22. SG and LG, are formerTBA clientswho allegethat TBA referreda child
for them to adopt,who had alreadybeen referredto anothercouple,and was no
longer availableto be adopted. This is a violationof seclion 63.212(2Xa)1.,
FloridaStatutes.

23. TA and DA are TBA clients who allege that TBA referredto them six
severely develoBmentallydisabled children who, when they had indjq-ateda
willingnessto adopt a child with mild behaviorproblems.This is a violationof
section63.212(2Xa)1.. FloridaStatutes

24. The A's further allegethat TBA advisedthem there was a healthychild
availablefor adoptionand that for $7000, the child would be held for them.
However,after payingthe addiiionalmoney,TBA allowedthe childto be adopted
FloridaStatutes.
by anothercouple. This is a violationof section63.212(2Xa)1.,

25. The A's furtherallegeTBA has violatedtheir rightsto privacyin violation

oJsection63.162(4), Florida
andRute65C.013,
FloridaStatutes, Administrative
Code.
26. KK allegesthat ;. Hedstromopenlydiscussedc identialinformation
regardingSG and l-G during a telephoneconversationshe had with Ms
Hedstrom. This is a violationof section63.162(4),FloridaStatutes,and Rule
65C.013,FloridaAdministrativeCode

27. DPandKPallegethatMs.Hedsirompresented DonnieHedstrom to them

as a licensedsocialworker,that Mr. Hedstromwas unableto answerany
questionsthat a licensedsocialworkershouldbe ableto answer,andthatTBA
did nothingforthe $3,500.00paidto it bythe couple.Thisis a violationof section'
63.212(2)(a\1.,FloridaStatuies.
28. DP and KP allegethatTBA,as of thisdate,has notprovided themwith a
FinalOrderTerminating ParentalRightsandthatas a result,theyfeardisruption
of adoption.
Thisis a violation
of sectjon Florida
63.039(1), Statutes.

29. DP and KP allegethat Tedi Hedstromsignedpapersnotarizedin the

adoption,as a witness.Notarizinga documentwherea witnesshas a linancial
interestin the underlyingtransactionis a violationsection1'17.05(5Xb)1
e.,
FloridaStatutes,a violationof section63.039(1),FloridaStatutes,and is a
violationof TBA'Sownwrittenpolicyandprocedure.
30. BH familyallegesthat, up untilarrivingin Vietnamfor a first visit,they
were guaranteed by TBA staff that the threechildrenthey had beenreferred
were100o/o availableand that,priorto the couplettaveling,TBA knewthis was
notlrue with ragardto two of the threechildren.Knowingthis information, TBA
continuedto acceptfull fees,to assurethe coupleof the availability of these
children,toldus thatall threechildrenwerehealthyandencouraged ourfamilyto
travslto Vietnam.Thisis a violationof section63.212(2)(aX.,FloridaStatutos.

31. BHsallegesthat,as partof the adoptionfee,theywereforcedto payTBA

$500per child,claiming
an additional the fee was a'humanitarianfee'to be
usedto buildan orphanage.This is a violationof section63.097(2),
Florida
Statutes.
32. sH familyallegesthatTBA informedthemtheyhadtwochildrenavailable
for refenaland that they neededto send in approximately $9000to hold the
aftersendingTBAthe money,theywereinformedthatoneof
child. lmmediately
the childrenwas no longeravailable,becausethe childhad beenmovedfrom
one provinceto another. The SHs allegethat it is illegalin Vietnamfor an
orphanedchild to be movedfrom one provinceto anotherand that TBA'
misrepresenied of the childfor adoption.This is a violationof
the availability
section 63.212(2)(aX.,Florida
Statutes.

33. SH allegesthey informedTBA they did not want to be involvedin a

'direct"adoptionbecausetheybelievedit encouraged thesellingof babies.TBA
ensuredthemthe childrentheywere going to adopt would be childrenwho had
been in fostercare whoseparent'shad had thelr parentalrighlsterminated.
However, it was learnedat the G&Rceremony, afterhavingreceivedthe child,
'direct"
thatthe childthey adoptedhad never,been in fostercare and was a
'direct"
adopt,theywould
adoDted child. Hadthe SH'sknownthe childwas a
not have gone foM! with the' adoption.This is a .olationof secton
63.21212\(al1.,
FloridaStatutes.
34. CH allegesTBA chargeda $6500'countryfee" for a country,Ukraine,
whichdoesnot allow"countryfees.'Thisis a violationoi sections63.212(2)(a)1
and63.097(2),
Florida Statutes.
The abovereferenced groundsto rgvokethis license
violationsconstitute
in thatthe abovereferencedconductconstitutes a violationof the provisions
of
Chapters 409 and63, FloridaStatutes,andihe RuleswithinChapter 65C-15,
Florida administrative
code.

OF RIGHTS
NOTICE
Thisdecisionconstitutes finalagencyactionunlessa personwhois substantially
afiectedby it submitsa wriftenrequestfor a hearingthat is receivedwithin
twenty-one daysfromthe date on whichhe or she receivesthis noiice. This
requestfor hearingmustalsomeetthe reqlirements of section120.562,Florida
Statutes,and eitherRula28-106.2O1 or Rule28-106.301, FloridaAdministrative
Code,or else it will be dismissedas requiredby section120.569(2)(c),
Florida
Statutes.
That law and thoserulesrequirethe wriftenrequestfor hearingto includelhe
followinginformation:
1. Thenameandaddressof eachagenoyaffectedandeachagency's fileor
identification
numberif known;
2. Thename,addressandtelephone humberof the personwhois askingfor
the hearing(thepetitioner);
3. The name and, address and telephonenumber of the petitioner's
representative, if any;
4. An exDlanation of howthe Detitioner's
substantialinterestsare or will be
atfectedbythe agencydecision;
5. A statementof whenand howthe petitioner receivednoticeof theagency
decision
6. A statementeitherthat the oetitionerdoes not disputethe facts upon
whichthe districtreliedin makingits decisionOR a statementthat the
petitionerdoesdisputethosefactsalongwitha listof thefactsin dispute;
7. lf factsare in dispute,a statementof thefactsas the petitioner
perceives
themto be:
8. A statementof the specificrulesor statutesthat the petitionerbelieves
requiretheagencyto reverseor modifyitsdecision; and
L A statementsayingwhatactlonthe petitioner wantsthe agencyio takein
the matter.
Failureto requesta hearingin writingandwithinthe timeframesrequiredin this
noticeor failure to providethe informationrequiredby the law and rules
govemingrequestsfor Chapter120 Hearingsconslitutes a completewaiverof
any right that a substantiallyaffectedpersonmay have to challengethis
decision,and will result in the entry of a Final Order affirming this
AdministrativeComplainL
10
The requestfor hearingmust be receivedby the followingpersonat the fo owing
adclresseson or before twenty-one(21) days on which this notice was first
receuedby the personrqquestingthe hearing:

RogerLD Williams KarenKugell

AssistantGeneralCounsel ActingAgencyClerk
Department
of Children
andFamiiies Department of ChildrenandFamilies
P.O.Box2417 Officeof theGeneral Counsel
FL32231-0083
Jacksonville, 1317Winewood Blvd.,Bldg.2,
Rm.204
Tallahassee, FL 32399-0700
STATEOF FLORIDA
DEPARTMENT OF CHILDREN
AND FAMILIES

ThomasSiCeci
ProgramAdministrator

11