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STATEOF FLORIDA ' DEPARTMENT OF CHILDRENAND FAMILIES

E)ilIIBITA

INTHE MATTER OF

TheRevocation

Of

-License AsA Child

PlacingAgency ln

TheState Of Florida

TediBear Adoptions, Inc.

1415Atlantic Blvd.

NeptuneBeach, FL 32266

CertifiedMail .

Returnreceipt reqirested

AMENDEDADMINISTRATIVE

COMPLAINT

YOUARE HEREBYNOTIFIED that the Stateof Florida,Department

of Children

and Families,(hereinafter 'Department") intendsto revokeyour licenseas a

child-placingagency, As groundsfor the revocation,the Depaftmentstates as

follows:

  • 1. The Departmenthas authorityto take this action pursuant to section

409.175(8XbX2), Flofida Statutes.

'Respondent" or

  • 2. The Respondent,

Tedi BearAdoptions, Inc., (hereinafter

TBA") is a Floridanon-profit corporation, whose registeredagent is Tedi

Hedstrom.

  • 3. The Respondentis licensedas a child-placingagency under Chapter

409.175,Florida Statutes, and Rules 65C-15, Florida Administrative

Code.

  • 4. On October2 and 3, 2002, after receiptand investigationof multiple

complaintsfrom cunent and former clients and former employees, and pursuant

to Rule65C-15.004, Florida Administrative

Code, an unannouncedon-site visit

was made to this Respondentby LicensingSpecialist Taffi/ Compainand

OperationalReview Specialist Carol Hutcheson.As a resultof this visit the

followingviolations of FloridaStatutes and the FloridaAdministrative

code were

discovered.

A, CompainReviow

  • 5. As of the dates of our complaintinvestigation,

TBA did not have the

requiredaudits for the yearsended June 30, 2001or June 90, 2002. Thisis a

violationof Rule65C-15.010(3),

Florida Administrative

Code.

  • 6. ProgramDirectors working for this Respondenthave been located

residingin other states.

ProgramDirectors for this Respondentperfonn

caseworkfunctions such as: recruilingadoptive clienis; providing the clientwith

a!l paperwork(other than the homestudy)for INSapproval; assisting clients with

all papeMork neededto completethe dossierto submit to the country;

answeringall country-speciflcqueslions; and communicating with the facilitators

regardingreferrals, travel dates and foreign country adoption processes. These

individualsalso maintain the originalconfidential client files in theirhomes until

the familyis backin the UnitedStates wiih theiradopted child, at whichiime,

theyreportedly return these records to TBA.

Rule65C-15.003(4),

Florida Admiriistrative

Code, states that:

"a licensedagency may operate a branchor satelliteoffices

withoutseparate licenses for thoseoffices. However, each

branchor satelliteoffic€ must be disclosedin the application

for licenseby submittinga copyof HRSForm 5135 for each

office.lf ihe agencyopens a branchor satelliteofflce during

thelicensed term, the agencyshall file HRS Form 5135 not

lessthan 10 days prjor to the openingof the newoffice.".

Th€oul-of-state program directorswere conductingTBA businessout of their

homes. Suchooerations constitute a branchor satelliteoffice for TBA.TBA'S

applicationfor licensuredid not reportit hadihese satellite oftices as required.

Assuch, this is a violationof Rule65C-15.003(4),

Florida Administrative

code-

  • 7. Educational

personnel

verification was notavailable in anyofthe ProgramDirectors'

filesreviewed. This is a violationof Rule65C-15.016(1),

Florida

AdministrativeCode, which requires that the agencyshall have available on site

theeducational

qualifications

of ernployeesto veriv thatthey meet the standards

sotforth in 65C-'15.017."

  • 8. Collegedegrees were not in thepersonnel files of formeremployees Amy

Bleich,Wendy Landessor DeidraDudley. This is a violationof Rule 65C-

Code, which requires 'the agencyto havea

15.016(2),Florida Administrative

personnel file with a copyof a diplomaor degreefor each emPloyee.'

  • 9. Rule65c-15.016(2),

Florida Administrative

cod6, requirss:

the agencyto

which would

have a peKionnelfile for each employee

include the

following: application for

employment:verification of screeningrequirements being

met:employees' starting and termination dales and reasons

for termination;annual

performanc€evaluations and any

disciplinaryactions taken; copy of diplomaor degree;and

trainingrecotd and conferences attended."

Five of the personnel files revieweddid not containrequired verification of

screeningrequirements and six of the personnelflles revieweddid not contain

adequaleverification that

employees were meeting training requirements.

. Regardingvedfication of screeningrequirements:

As part of the re-licensure process,Tedi Hedstromexecuted a Background

ScreeningAffidavit affirming that dll personnelof this agency "have

been

fingerprintedand are in compliancewith the backgroundscreening requirements

ofsection 409.175, F.S.'

Section435.01, Florida Statules providesthat 'lwlhenever a background

screeningfor employmentor a backgroundsecurity check is requiredby lawfor

employment,unless o shallapply."

wise providedby law, the prov

ns of this chapter

KellyFrasier -

of

No proofof fingerprintcheck in employeefile. This is a violation

is con$aryto the

Rule 65C-15.016(2),Florida Administrative Code, and

BackgroundScreening Affidavit contained in the licensurefile.

ShannonStorie -

No proofof

fingerprintcheck in the employeefile. This is a

Florida Administrative

code' and is contraryto

violationof Rule65C-15.016(2),

ihe BackgroundScreening Affidavit contained in the licensurefile

WendyLandess -

Affidavitof GoodMoral Character not signed by employee.

VickieBrown (Boyd) -

The FPSScheck verification was not in employee'stile

Florida Administrative

Code, and is

This is a violationof Rule65C-'15.016(2),

contraryto lhe BackgroundScreening Affidavit contained in thelicensure file.

r

Regardingverification of trainingand conferencesrequirements

(Rule 65C-

15.018(2),Florida Administrative code, requires15 hours of in-service

trainingannually):

Tedi Hedstromadmitted to fabricatingcerlificates of attendancefor TBA

employees.According to a former employee,TBA would create training

certificatesfor employeeswho

did not actuallyattend the training,and the

just priorto ils annual

in complianceThis is a

certificateswere then includedin the employee'sfile

licensurerenewal audit, to makeappear that TBA was

violationof Rule 65C-15.018,Florida Administrative Code. Also, knowingly

providingfalse informationconstitutes a violationof Section63'212

FloridaStalutes, and is a criminaland administrative

offense-

(2)(a)1.'

'

Otherviolations are as follows:

.

'

.

DonnieHedstrom -

Signedas supervisoron hisown training log on April27

"TBA

a February19, 2002

In-

was provided.

year. This is a violation

Code.

and 29,2002.There was alsoan entryfor

Service"-with no descriptionof the contentof the trainingthat

Documentationfor traininghas

not been recorded this

ofRules 65C-15.016(2)

and 65C15.018(2),

Florida Administrative

VickieBrown, Director of SocialWork - Onlyhad

logged,none of whichcould be verifiedand

a lotal of 9 traininghours

which is lessthan the required15

Florida Administrative

Code.

hoursand is a violationRule 65C-15.018(2),

r

Amy Bleich -

Her performanceevaluation completed by Tedi

Hedslrom,

listedher position as "Client SupporuProgramDirector." She had a totalof

  • 59 hours of training per her training

documentationto supportthe log

log.

However,lhere was no

entries.This is a violalionof Rule 65C-

15.016(2),Florida ,l

rinistrativeCode, and a violatiol

FloridaAdministEtive Code.

dle65C-15.018(2),

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

trainingmaterials to 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),

Florida Administrative

Code.

DeidraDudley -

>

TBAs employeefile for Ms. Dudleycontained no employeeapplication.

Thisis a violationof Rule65C-15.016(2),

Florida Administrative

Code.

>

Withoutdocumentation of employmentof Ms. Dudleyby TBA, an agency

relationshipcannot be establishedthat would authorizeMs. Dudleyto

have possession of these confidentialrecords. This is a violationof

section 63.'162(2), Florida Statutes and Rule 65C-15.013, Florida

AdministrativeCode.

>

Thereare no trainingdocuments in thisemployee's file. This is a violation

of Rules65C-15.016(2)

and 65C-15.018(2),

Florida Administrative

Code.

> There were no recordsof backgroundchecks performed.This is a

violationof section435.05, Florida Statutes, and Rula 65G15.016(2),

FloridaAdministrative

Coda, and is contraryto the BackgroundScreening

Affidavitcontained in the licensurefile.

  • 10. Confidentialadoption records are maintainedout of state by Program

Directors,and TBA maintains not evena copyof theserecords. Only after the

familyreturns to the UnitedStates with the adoptedchild are the originalfiles

mailedto TBAfrom the out-of-statedirectors. Failing to maintainfiles on siteis a

violationof Rules 65C-15.031,65C-15.032 and

AdministrativeCode.

65C-15.034,Florida

  • 11. As of October 15. 2002. TBA'Swebsite located on the Internetat

http:/fu/ww.tedibearadoptions.org/

did not includethe Respondenta .Florida

Licensenumber of the agency,which is a violationof Seclion63.212(1)(9),

FloridaStatutes and Rule65C-15.002(9),

Florida Administrative

Code.

  • 12. Specificauthority for Rule65C-15.0!7(1), Florida Administrative Code, is

containedin ChaDters63 and409, FloridaStatutes. This Rule requires that the

agencydirector shall have a mastedsdegree in socialwork or a relatedarea of

studyfrom an accreditedcollege or universityand

at leasttwo years'experience

in humanservlces or childwelfare programs.A bachelor'sdegree in socialwork

or a relatedarea of studyfrom an accreditedcollege or universityand four years

of experiencein humanservices or childwelfare programs may be substituted. A

doctoratedegree in sociatwork or a relatedarea of studymay be substitutedfor

oneyear of therequired experjence."

Ms. Hedstrom,Executi Directorof TBA, falsifiedher en

)ymentapplicaiiori

by indicatingshe has ra BA,/BSdegree with a majorin SocialWorllEducation:'

However,her resumeshows she hasa BA with a majorin Educationfrom the

Universityof NorthFlorida, '1987 anda minorin SocialWork from FloridaState.

University.When questioned abouther applicationshowing a majorin social

workand her resume showing a minorin it, sheadmitted that she does not have

a degreein socialwork and that thoughshe attendedclasses, she did not

graduatefrom FloridaState Universiv. The reviewerverified that Tedi

Hedstrom'sBachelois degree is in Educationonly. Knowingly providing false

informationconstitutes a violationof Section63.212 (2)(a11., which is a criminal

andadministrative offense.

Accordingto Pam Graham,MSW, the AssistantDean of the FSU Schoolof

SocialWork, teachingexperience is not consideredequal to social work

experience.Ms. Hedstromdoes not possessthe educationalcredentials for

beingan executivedirector of a child-placingagency. This violates Rule 65C-

  • 15.01 7(1 ), FloridaAdministrative

Code.

  • 13. The Directorof SocialWork, Vickie Brown,has a Mastedsdegree in

Education(Special Ed.) from the Universityof NorthFlorida, 1984. Her

prior

workexperience was as a taacherfor the DuvalCounty School System, 1997-

2000and she also worked for the OkeechobeeSchool Board from 1991 till 1997.

Accordingto Pam Graham,MSW, the AssistantDean of the FSU Schoolof

SocialWork, teachingoxperience is not consideredequal to social work

experience.As such,Ms. Browndoes not havethe requiredcredentials to hold

the position of Directorof SocialWork. Thisis a violationof Rule65C-15.017(2),

FloridaAdministrative

Code.

  • 14. DonnieHedstrom is a formeradoption caseworker

admits he has

for TBA.Mr. Hedstrom

conducted adoption home studies and post-placement

visits/reports. However,Mr. Hedstrom possessesa Bachelordegree in

Government. He has no socialwork experienceeither in schoolingor

employment.His previousemployment history was as

previous

car

an owner of a

dealershipin Jacksonvillefrom 1986 until he beganworking for TBA. Mr.

Hadstromis

not qualified to perform home studies and

post-placement

supervisionvisits as a socialworker. Thisis a violationof Rule65C-15-017(3),

FloridaAdministrative

Code.

  • 15. Requirementsof the adoptive home study done by DonnieHedstrom on

Rs wereabsent and/or inadequaie. Deficiencies

included no documentationof

discussingchild care planswith the applicant,who was a single-parentwho

worksoutside the home;no documentationof discussingattitudes and feelings

of the applicani'sfamily, the extendedmembers or significantothers, toward

adoptivechildren; no documentationof addressingthe applicant'splan for

djscussingthe adoptionwith the child;the adoptivechild's attitude toward the

birth parents was 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

inadequatedetail or examptesof the applicantsability to

copewith problems.

The overall quality of the home study reviewedwas poor and did not

substantiallycomply

AdmlnistrativeCode.

l the requirementsof Rule C-15.028,Florida

16.

17.

Code.

18.

Exhibit

"A",

'B'indicated

19.

Patti Mcclaughlin -

Had no.collegedegree and servedas program

directorfor Chinaand HongKong. This violatesRule 65C-15.017(3),

Florida

AdministrativeCode:

CheryaBor -

Had no collegedegrce and servedas ProgramDirector for

Florida Administrative

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

A requirementfor TBA'Srelicensure was providinga correctiveaction plan

for deficienciesnoted during the June 6, 2002 relicensuremonitoring, (see June

11, 2002 correspondencefrom Linda Rosenthalto Tedi Hedstromaftached as

requesting a

performance improvement

plan). The attached

2002 (attachedas Exhibit

correctiveaction plan submittedby TBA on June 21 ,

that the deficiencieshad been resolved. However,the deficiencies

sixteen of this AdministrativeComplaint,

alteged in paragraphs four through

demonstratethat TBA has failedto

substantiallycomply with its correctiveaction

plan was requiredfor relicensingin 1999

and

"D'

respectlvely)and many of the

plan. Additionally,a correctiveaction

'c"

and in 2000, (attachedas Exhibit

deficienciesnoted at thosetimes are still continuingto occur.

B. HutchosonRoview

In additionto reviewingemployea files and otheragency documentation in

orderto determineif licensingrequirements were beingmet, also reviewedwere

11 fites of familiesinvolved with TBA for internationaladoption and two files of

familiesparticipating in domeslicadoptions. The followingdeiails various other

violationsof FloridaSlatutes and the Flolida AdministrativeCode discoveredin

these reviews. Due to confidentialityand'exemption requirements, initials shall

refer to

the adoption applicants and adoptive parents.

A

list

with

corrEsponding names shall be served on tho Respondentalong with this

AdministrativeComplainL

TheAs File

The A's allegeTBA

parents

failedto protectlheir confidentiality. Releasingan adoptiva

identitywithout their written consentis a violationof section63.162(4)'

FloridaStatutes, and Rule65C-013, Florida Administrative Code

The L's File

This file indicatedthat the adoptivefamily

childrenfrom Moldovain January2001.

in the file.

Failingto conduct

arrivedback in the UnitedStates with

There were no post plac€mentreports

post placementreviews for these adoptionsis a

Florida

violationof section63.125(5), Florida Statutes, and Rule65C-16.010(4),

AdministrativeCode.

The S's File

After reviewingthis file it was impossibleto determinewho actually placed the

childin the home. Thisis a violationof 65C-15.030('1Xd),

Florida Administiative

Code.

The R's File

This file containsa letterdated November15, 2001 from Tedi Bear Adoptions

stating the requirementsfor

containedno

post placement visits.

However, the record

post placementreports. This is a violationof Section63.125(5)'

FloridaStatutes. and Rule65C-16.010(4),

Florida Administrative

Code.

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), Florida Statutes, and Rule65C-16.010(4)' Florida

AdministrativeCode.

The B's File

This file did not contain any

post placementreports. When questioned,the

ExecutiveDirector for TBA telephonedthe adoptivemother to ask who had done

'the

Dostolacement work. The adoptivemother reported'thatDonald Hedstrom

TBA was only ableto locateone

conductadthe visits. The ExecutiveDirector for

of the three requiredreports.

'aftdr

the establisheddue

However,this reportwas completedfive months

date.This,is a violationof Section63.125(5)' Florida

Statutes,and Rule65C-16.010(4), Florida Administrative Code.

TheKandHFiles

Upori arrivaiat ttte agencythe

ctientfiles that neededto be

ExecutiveDirector for TBA was given a list of

reviewed.The K and H fileswere both requestedat

' that time. the ExecutiveDirecior for 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

they were clientsof a differentagency, New

these families,.andexplained thai

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

statedthat the answerto both questions was

"no."

moneyfrom eitherfamily. She

On the secondday of the reviewa staff memberapproached the reviewersand

askedfor the H file, indicatingthat

she had some informationto add to the file.

The reviewersstaied that the ExeculiveDirector for TBA informedus that there

wasno filefor this family. The reviewers also stated that, if thiswas incorrect,

the iile should be pro

both families.

,ed for review. A file was subs

lently producedfor

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-placingagencies for these families,it

should not be in possessionof their confidentialadoPtion records. Having

informationregarding these non-clientfamilies is a violationof 63.162(4),Florida

,"

Statutes.and 65C.013.Florida Administrative Code.

Tedi Hedstromcould not explainwhat the relationshipis betweenTBA and these

families.

However,when questioned about this relationship,the Executive

Directorfor TBA indicatedthat she did collecta $2000 networkingfee from these

families. Section63.097, FloridaStatutes outline the fees which an adoption

entity may access against an adoptive parent.

statute that allows the assessment of a

There is no

provisionin this

Accotdingly,

"networking" fee.

assessmentof such a fee is a violationof section63.097, Florida Statutes, and

Rule65C-15.010, Florida Administrative Code.

  • 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., Flodda Statutes.

  • 21. JM allegesthat a websiteowned by TBA known as -Project Faith,"was

usedto solicitdonations using fabricated stories about childrenbeing abused or

sick. Thisis a violationof 63.212(2Xa)1.,

Florida Statutes, and Rule 65C-15.0'13,

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 Florida Statutes

..

  • 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 paying the addiiionalmoney, TBA allowedthe childto be adopted

by anothercouple. This is a violationof section63.212(2Xa)1., Florida Statutes.

  • 25. The A's furtherallege TBA has violatedtheir rightsto privacyin violation

oJsection 63.162(4), Florida Statutes, and Rute 65C.013, Florida Administrative

Code.

  • 26. KK allegesthat

;. Hedstromopenly discussed c

identialinformation

regardingSG and l-G during a telephoneconversation she had with Ms

Hedstrom.

Thisis a violationof section63.162(4), Florida Statutes, and Rule

65C.013,Florida Administrative

Code

  • 27. DPand KP allege that Ms. Hedsirom presentedDonnie Hedstrom to them

as a licensedsocial worker, that Mr. Hedstromwas unableto answerany

questionsthat a licensedsocial worker should be ableto answer,and that TBA

did nothingfor the $3,500.00 paidto it bythe couple.This is a violationof section '

63.212(2)(a\1.,

Florida Statuies.

  • 28. DP and KP allegethat TBA, as of thisdate, has not providedthem with a

FinalOrder Terminating Parental Rights and that as a result,they fear disruption

of adoption.

This is a violationof sectjon63.039(1),

Florida Statutes.

  • 29. DP and KP allegethat Tedi Hedstromsigned

papersnotarized in the

adoption,as a witness.Notarizing a documentwhere a witnesshas a linancial

interestin the underlyingtransaction is a violationsection 1'17.05(5Xb)1 e.,

FloridaStatutes, a violationof

section63.039(1), Florida Statutes, and is a

procedure.

violationof TBA'Sown written policyand

  • 30. BH familyalleges that, up untilarriving in Vietnamfor a first visit,they

were guaranteedby TBA staff that the threechildren they

were100o/o

available and that,

had beenreferred

prior to the couplettaveling, TBA knewthis was

notlrue with ragardto two of the threechildren. Knowing this information,TBA

continuedto acceptfull fees,to assurethe coupleof

children,told us thatall threechildren were healthy and

the availabilityof these

encouraged our family to

Florida Statutos.

travslto Vietnam.This is a violationof section63.212(2)(aX.,

  • 31. BHsalleges that, as partof the adoptionfee,

they were forced to payTBA

an additional $500 per child,claiming the fee was a'humanitarianfee'to be

usedto buildan orphanage.This is a violationof section63.097(2), Florida

Statutes.

  • 32. sH familyalleges that TBA informedthem they had two children available

for refenaland that they neededto send in approximately$9000 to hold the

child.lmmediately after sending TBA the money,they were informed that one of

the childrenwas no longeravailable, because the

one province to another. The SHs allegethat

orphanedchild to be movedfrom one

childhad beenmoved from

it is illegalin Vietnamfor an

provinceto anotherand that TBA'

misrepreseniedthe availabilityof the childfor adoption.This is a violationof

section63.212(2)(aX.,

Florida Statutes.

  • 33. 'direct" adoptionbecause they believed it encouragedthe selling of babies.TBA

ensuredthem the childrenthey were going to adoptwould be childrenwho had

been in fostercare

whoseparent's had had thelr parentalrighls terminated.

SH allegesthey informedTBA they

did not want to be

involvedin a

However,it was learnedat the G&Rceremony, after having received the child,

'direct"

thatthe childthey adoptedhad never,been in fostercare

adoDtedchild. Hadthe SH'sknown the childwas a

and was a

'direct" adopt,they would

not have gone foM! with the' adoption.This is a .olationof secton

63.21212\(al1.,

Florida Statutes.

'country fee" for a country,Ukraine,

  • 34. whichdoes not allow "country fees.'Thisis a violationoi sections63.212(2)(a)1

$6500

CH allegesTBA chargeda

and63.097(2),

Florida Statutes.

The abovereferenced violations constitute grounds to rgvokethis license

in thatthe abovereferenced conduct constitutes a violationof the provisionsof

Chapters409 and63, FloridaStatutes, and ihe Ruleswithin Chapter 65C-15,

Floridaadministrative

code.

NOTICEOF RIGHTS

Thisdecision constitutes final agency action unless a personwho is substantially

afiectedby it submitsa wriftenrequest for a hearingthat is receivedwithin

twenty-onedays from the date on whichhe or she receivesthis noiice. This

requestfor hearingmust also meet the reqlirementsof section120.562, Florida

Statutes,and eitherRula 28-106.2O1 or Rule28-106.301, Florida Administrative

Code,or else it will be dismissedas requiredby section120.569(2)(c), Florida

Statutes.

That law and thoserules require the wriftenrequest for hearingto includelhe

followinginformation:

  • 1. Thename and address of eachagenoy affected and each agency's file or

identificationnumber if known;

  • 2. Thename, address and telephone humber of the personwho is askingfor the hearing(the petitioner);

  • 3. The

name and, address and telephonenumber of the petitioner's

representative,

if any;

  • 4. An exDlanationof howthe Detitioner'ssubstantial interests are or will be

atfectedby the agencydecision;

  • 5. A statementof whenand howthe petitioner receivednotice of theagency decision

  • 6. A statementeither that the oetitionerdoes not disputethe

facts upon

whichthe districtrelied in makingits decisionOR a statementthat the

petitionerdoes dispute those facts along with a listof thefacts in dispute;

thefacts as the petitionerperceives

  • 7. lf factsare in dispute,a statementof

themto be:

  • 8. A statementof the specificrules or statutesthat the petitionerbelieves

requirethe agency to reverseor modifyits decision; and

  • L A statementsaying what actlon the petitionerwants the agencyio takein the matter.

Failureto requesta hearingin writingand within the timeframesrequired in this

noticeor failure to provide the informationrequired by the law and rules

goveming requestsfor Chapter120 Hearingsconslitutes a

completewaiver of

any right that a substantiallyaffected person may have to challengethis

decision,and will result in the entry of a Final Order affirming this

AdministrativeComplainL

The requestfor hearingmust be receivedby the followingperson at the fo owing

adclresseson or before twenty-one(21) days on which this notice was first

receuedby the person rqquestingthe hearing:

RogerLD Williams

AssistantGeneral Counsel

Department

of Childrenand Famiiies

P.O.Box2417

Jacksonville,

FL 32231 -0083

KarenKugell

ActingAgency Clerk

Department of Childrenand Families

Officeof the General Counsel

1317Winewood Blvd., Bldg.2, Rm.204

Tallahassee,

FL 32399-0700

STATEOF FLORIDA

DEPARTMENTOF CHILDREN AND FAMILIES

ThomasSiCeci

ProgramAdministrator