Nov O8 O4 11:56a Dept Childen & Families 9047275513 p- STATE OF FLORIDA cere 22 DEPARTMENT OF CHILDREN AND FAMILIES IN THE MATTER OF Certified Mail 7003-1680-0000-0502-1508 Civil Penalty Against Return Receipt Request Sandra Ridgeway 10425 Ebbitt Road Jacksonville, Florida 32246 Cu dil ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that the Department has imposed a Civil Penalty in the amount of One Hundred Dollars ($100.00). 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 the Respondent by virtue of the provisions of Chapters 402,301 - 402.319, Florida Statutes. 2. The Respondent, Sandra Ridgeway, is licensed to operate Ridgeway Family Day Care Home in compliance with Chapter 402, Florida Statutes (F.S.), and Florida Administrative Code (FAC), Chapter 65C-20. 3. During an investigation on July 22, 2004, it was determined that the Respondent committed a violation of FAC Chapter 65C-20.009(3)(a), in that: While in the care of the Respondent, an eight-month-old infant suffered a fracture above the left ankle. According to the provider’s explanation, the injury may have occurred due to an older child picking up the infant and dropping her. Medical professionals believed a lack of supervision in the day care setting contributed this injury. 4. The above referenced violation constitutes grounds to levy this Civil Penalty pursuant to Chapter 402, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regutations for the operation of a Family Day Care Home. 5. Payment of this fine can be made directly to the Department of Children and Families. The mailing address ts: P.O. Box 2417, Jacksonville, FL. 32231, Attention: Chiid Care Licensure. Nov O98 O4 11:57a Dept Childen & Families 90472755139 P- Administrative Complaint ~ Sandra Ridgeway September, 2004 Page 2 TI F This decision constitutes final agency action unless a person who is substantially affected by it submits a written request for hearing that is received within twenty-one days from the date on which he or she first receives this notice. The request for hearing must also meet the requirements of Section 120.56, F.S., and elther Rule 28-106.201 or Rule 28-106.301, F.A.C., or else it will be dismissed as required by Section 120.569(2){c), F.S. That law and those rules require the written request for hearing to Include the following information: 1. The name and address of each agency affected and each agency's file or identification nurnber if known; 2. The name, address, and telephone number of the person who is asking for the hearing (the petitioner); 3. The name, address, and telephone number of the petitioner's representative, if any; 4. An explanation of how the petitioner's substantial Interests are or will be affected by the agency decision; 5. Astatement of when and how the petitioner received notice of the agency decision; 6. A statement that the petitioner does not dispute the facts upon which the agency relied but that it wants to exercise the right to be heard anyway OR a statement that the petitioner does dispute the facts upon which the agency relied and a list of the facts in dispute; 7. Aconcise statement of the facts as the petitioner perceives them to be, including the specific facts set out by the agency that the petitioner wants the agency to reverse or change; 8. A statement of the specific rules or Statutes that the petitioner believes requires the agency to reverse or modify its decision; and 9. A statement specifying what action the petitioner wants the agency to take in the matter. Failure to request a hearing In writing and within the time frames required in this notice or failure to provide the information required by the law and rules governing requests for Chapter 120 hearings constitutes a complete waiver of any right that a substantially affected person may have to Challenge this decision. Nov O08 04 11:57a Dept Childen & Families 9047275519 p- Administrative Complaint - Sandra Ridgeway September, 2004 Page 3 The request must be received by the following persons at the following addresses on or before twenty-one (21) days of the date on which this notice was first received by the person requesting the hearing: Roger L.D. Williams Paul Flounlacker, Agency Clerk Assistant General Counsel Department of Children & Families Department of Children & Families Office of the General Counsel P.C, Box 2417 1323 Winewood Bivd., Bidg. 1, Suite 407 Jacksonville, FL. 32231-0083 Tallahassee, FL. 32301 STATE OF FLORIDA, DEPARTMENT OF CHILDREN AND FAMILIES Program Administrator Nov 08 O04 11:57a Dept Childen & Families so47a7ests Administrative Complaint - Sandra Ridgeway September, 2004 Page 4 CERTIFICATION OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail 7003-1680-0000-0502-1508, Return Receipt Requested, in accordance with ss. 120.60(3), Florida Statutes, this (te day of September, 2004. STATE OF FLORIDA, DEPARTMENT OF CHILDREN & FAMILIES Linda Nz Smith Program Administrator p-

Docket for Case No: 04-004311