STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES IN THE MATTER OF A Civil Penalty Against Kid City USA-Sanford 2720 West 25" Street Sanford, Florida 32771 * ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that the Department has imposed a Civil Penalty in the amount of $300.00 and is revoking the facility’s Gold Seal Quality Care Designation. As grounds for the imposition of this penalty, the Department states the following: 1. The Department of Children and Families, State of Florida, has jurisdiction over Respondent by virtue of the provisions of Sections 402.301-402.319, Florida Statutes. On November 4, 2011, the Department issued Jiconse #C18SE0245 to the respondent to operate Kid City USA-Sanford, located at 2720 West 25" Street Sanford, Florida 32771, as a Child Care Facility ia accordance with Chapter 402, Florida Statues, and Rule 65C-22, Florida Administrative Code. ind 3. Respondent committed a Class 1 licensing violation of 65-22,004(3) Florida Administrative Code, with respect to Medication. On April 20, 2012, written instructions for dispensing # Albuterol, were not followed in that the child was not given the medication after “The inspection for April 20, 2012 is attached as Exhibit “A. For this violation, $300 fine is imposed in accordance with Section 402.31 0(1 0a), medication, the first day. the Department imposes a Florida Statutes. 4, Gold Seal designation. The violation described in paragraph three constitutes a Class | violation as defined in rule 65C-22.012(3)(b), Florida ‘Administrative Code, Section 402.281, Florida Statutes, requires that the department terminate yout Gold Seal designation. Therefore, the department is terminating your Gold Seal designation. You will be ineligible for Gold Seal designation until you have operated for a period of two years without a Class 1 violation. 5, The above referenced violations constitute grounds to levy this Civil Penalty pursuant to s. 402.310(1Xa), F. S., in that the above referenced conduct of Respondent constitutes 2 violation of the mininzum standards, rules and regulations for the operation of a Child Care Facility. Fil ivi 'iled August 24, 2012 4:00 PM Division of Administrative Hearings PAYMENT OF FINE, IF NOT CONTESTED Payment of this fine can be made by money order or cashier’s check directly to the Department of Children and Family Services, The mailing address is Department of Children and Families Attention: Child Care Licensing Office 400 West Robinson Street S-912 Orlando, FL 32801 a IF YOU BELIEVE THE DEPARTMENT’S DECISION IS IN ERROR, YOU MAY REQUEST AN ADMINISTRATIVE HEARING TO CONTEST THE DECISION, YOUR REQUEST FOR AN ADMINISTRATIVE HEARING MUST BE RECEIVED BY THE DEPARTMENT WITHIN 21 DAYS OF YOUR RECEIPT OF THIS NOTICE. FAILURE TO REQUEST AN ADMINISTRATIVE HEARING WITHIN THE 21 DAYS PROVIDED SHALL CONSTITUTE A WAIVER OF THE RIGHT TO A HEARING. You may submit your request for an administralive hearing to the Department af the following address: T. Shane DeBoard, Esquire Department of Children and Families C/O District Legal Office, $-1129 400 West Robinson Street Orlando, Florida 32801-9425 Please note that a request for an administrative hearing must comply with section 120.569(2\(c), Florida Statutes, and Rules 28-106,201(2), Florida Adminisiralive Code. Those provisions, when read together, require a petition for administrative hearing to inclade: (a) The name and address of each agency affected and each agency’s file or identification number, if kaown; (b) The name, address, and telephone number of the petitioner; the name, address, and telephone number of the petitioner’s representative, if any, which shall be the address for service purposes during the course of the proceeding; and an explanation of how the petitioner's substantial interests will be affected by the agency determination; (c) A statement of when and how the petitioner received notice of the agency decision; (d) A statement of all disputed issues of material facts. If there are none, the petition must so indicate; (c) A concise statement of the ultimate facts alleged, including the specific facts the petitioner contends warrant reversal or modification of the agency’s proposed action; (f) A statement of the specific rules or statutes the petitioner contends require reversal or modification of the agency’s proposed action; and (g) A statement of the relief sought by the petitioner, stating precisely the action petitioner wishes the agency to take with respect to the agency’s proposed action, Section 120.569, Florida Statutes, and ruie 28-106.201(4), Florida Administrative Code, require that a petition to be dismissed if it is not in substantial compliance with the requirements above. STATE OF FLORIDA, DEPARTMENT OF CHILDREN AND FAMILIES //| - Rene Akins Regional Safety Operations Manager Child Cure Services CERTIFICATE OF SERVICE IHEREBY CERTIFY that a true copy hereof was sent to Stephanie Lopez, Director of, Kid City USA-Sanford, 2720 West 25" Street Sanford, Florida 32771, by U.S. Certified Mail, Return Receipt Requested, Certificate # \C 2) Or ind by U.S. Regular Mail, in accordance with s. 120.60(3), Florida Statutes, this day of, ant AU 2012. CC CERTIFICATE OF SERVICE ] HEREBY CERTIFY that a true copy hereof was sent to Carmen Pena, Owner of, Kid City USA-Sanford, 219 Palmetto Concourse Longwood, Florida 32779, by U.S. Certified Mail, Return Receipt Requested, Certificate # 0 =a by U.S. Regular Mail, in accordance with s. 120.60(3), Florida Statutes, this is day of R SOW 22012, \ 400 West I Robinson Sweet S-912 Orlando, Florida 3280} Child Care Facility Information __ CD Nib: C1B8E0245 Name: Kid City USA-Saford Address; 2720 W. 25th St. Sanford, FL 32771 Capacity: 406 Inspection Information Type: Complaint __ Date: 04/20/2012 ArrivaliDeparture: 08:05 AM to 00:05 AM StafPresent: 15 Children Present: 112 Complaint - Received: 04/19/2012 Completed: 07/20/2012 This is e complaint report, which documents ihe inspection resulis for only thous standards thai were reported to be out of compliance with Hoensing requizemants, GENERAL REQUIREMENTS (65C-22.001) 5. Supervision 65C-22.001(6)(a}-(d), 65C-22.001(6)(f), 65C-22,002(4){c)2. & 65C-22.007 (2)... ... . Compliance HEALTH REQUIREMENTS (65C-22.004) 49. Medication 65C-22.004(3) Noncompliance Noncompliance Description{s) Whitien instructions for dispensing a medication, Albuterol, ware not followed in that the chifd was nol given the medication for three days of attendance. Oue Date: Completed al time of inspection Violation Level: Class 1 . StatutelAdmiaistrafive Code 85C-22,004 (3){a) The faciity mast nave written authorization from the custodfal perent or legat guardian to dispense prescription and non-prescription medications, This euthorizelion must be dated and signed iy the custodial parent or Jegal guardian and contain the chiki’s name; the name of the medivation to be dispensed; ant date, tie and amount of dosage fo be given, This record shell be infialed or signed by the facility personnel who gave the madication. (0) Any known allergies to medication or special restrictions must also be documented, inaintained in the chile's fe, shored with staff and posted wilt slored medication, . {c) Prescription and non-prescription medication brought fo the chitt care laciity by the custodial parent or legal guardian must be in the original canteiner. Prescription medication must have a Jabel stating the neme of the physician, chiki's neme, name of the medication, and medication directions. Al prescription and non-prescription medication shell da dispensed according f0 writen directions on the prescription label or printed tnanutacturer's label. {@) In the event of an emergency, non-prescription macication that is not brought in by the custodial parent or lage! guardian can be dispensed only ifthe focifly hes written authorization trom the custodial parent or legal guardian fo do sa. {e} Any mocieation dispensed uniier these condifons must be documented in the child's fie and the custodial parent or tegal guardian nust be notifeed on the day of occurrence. (0) The facitty must maintain a record for gach child receiving medications thet documents fhe fui! name of the child, the name of medication, the ¢fate and fime the medication was dispensad, the amount and dosage, anc the name of the person who dispensed the medication. The record Shall be maitained for @ minimum of four (4) months after the lest dey the child received the dosage, {9} Al medicines must have chitd resistant caps and shall be slored separately and locked or out of a chikt's reach. (h) Medication which hes expired or is no longer being administered shal be retuned fo the custodta! parent or legal guardian or discarded if the child is no longer enroled in care af the lactity ‘Aulhority: Sections 402.301 - 319, Florida Statutes April 20, 2072 Chapter 650-22, Florida Administralive Code Page 1 of 2 Child Care Facility Information 4D Number: C18SE0245 ame: Kid Clty USA - Sanford Received by: Gonnis Cooper Date: 04/20/2012 Authority: Sections 402.301 - .319, Florida Statutes Chapter 65C-22, Florida Administrative Coce inspected by: David Meconites April 20, 2012 Page 2 of 2

Docket for Case No: 12-002856