Board of Massage Therapy FLORIDA

FLORIDA | Board of Massage Therapy

AGENDA OUTLINE September 14, 2016

9:00 am, EST

Meet Me #: (888) 670-3525

Participation Code: 2597709961

Lydia Nixon, LMT Chair Kama Monroe Executive Director

FLORIDA |

Board of Massage Therapy

AGENDA OUTLINE September 14, 2016

9:00 am, EST

Meet Me #: (888) 670-3525

Participation Code: 2597709961

Lydia Nixon, LMT Chair

Kama Monroe Executive Director

Florida Board of Massage Therapy of 3 AGENDA – General Business Meeting Conference Call June 8, 2016

Meeting will be called to order at 9:00 a.m., or soon thereafter, on Wednesday, September 14, 2016.

ADMINISTRATIVE PROCEEDINGS Applicant Informal Hearing

1. Wang, Zehong

Applicants with History

2. Cai, Hongfang

3. Cui, Haiyue

4. Harry, Margaret E.

5. Hinkle, Tim

6. Mackert, David Anthony

7. Maruca, Joe

8. Quan, Shijia

9. Steele, Shelly

10. Wang, Yuexia

Applicants with Foreign Education

11. Wanderley Sobrinho, Helio Oliveira Petitions for Variance or Waiver

12. Baize, Tiera

13. Kumar, Jessica

WEDNESDAY, September 14, 2016WEDNESDAY. September 14. 2016

Meeting will be called to order at 9:00 a.m., or soon thereafter, on Wednesday, September 14, 2016.

ADMINISTRATIVE PROCEEDINGS

Agglicant Informal Hearing

1. Wang, Zehong

Agglicants with History

2.

3.

8.

9.

Cai, Hongfang

Cui, Haiyue

Harry, Margaret E.

Hinkle, Tim

Mackert, David Anthony

Maruca, Joe

Quan, Shijia

Steele, Shelly

10. Wang, Yuexia

Applicants with Foreiqn Education

11. Wanderley Sobrinho, Helio Oliveira

Petitions for Variance or Waiver

12. Baize, Tiera

13. Kumar, Jessica

Florida Board of Massage Therapy AGENDA — General Business Meeting Conference Call June 8, 2016

Page 2 of 3

GENERAL BUSINESS DISCUSSION

Federation for State Massage Therapy Boards 2016 Resolutions

14. 2016 Resolutions

OLD BUSINESS

NEW BUSINESS

ADJOURN

Florida Board of Massage Therapy of 3 AGENDA — General Business Meeting Conference Call June 8, 2016

FLOR A \

Board of Massage Therapy REQUEST FOR INFORMAL HEARING

Zehong Wang DOB:— File No: 84742 Completed: —

School approved by California Bureau for Private Postsecondaw Education

47. Zehong Wang Applicant was present without counsel. Action Taken: After discussion, Ms. Phillips moved to deny the license as applicant is deficient hours of the following educational requirements for licensure: 85 hours in Basic Massage Theory and History, 55 hours in Clinical Practicum, and 15 hours in Theory and Practice of Hydrotherapy. Motion seconded by Mr. Brooks, which passed unanimously.

Report prepared by Samantha Jenkins

Mission: To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

Rick Scott Governor

Celeste Philip, MD, MPH

Surgeon General and Secretary

Vision: To be the Healthiest State in the Nation

Florida Department of Health Division of Medical Quality Assurance • Bureau of HCPR 4052 Bald Cypress Way, Bin C06 • Tallahassee, FL 32399-3256 PHONE: (850)245-4444 • FAX : (850) 412-2681

FLORIDA BOARD OF MASSAGE THERAPY NOTICE OF HEARING

August 18, 2016 File:84742

To: Zehong Wang

1121 Whitmore St. Unit #a Monterey Park, CA 91755

YOU ARE HEREBY NOTIFIED that the Florida Board of Massage Therapy will consider your application at the following meeting. Date: September 14, 2016 Time: 9:00 am Type: Conference Call Meet Me Number: (888)-670-3525 Participation Code: 2597709961 Your participation is not required. However, all respondents are encouraged to participate in the conference call. If you do not participate, the Board may require your appearance at a regularly scheduled Board meeting. Should the Board require your appearance, you will be required to appear at one of the next two regularly scheduled meetings. This may further delay a decision on your licensure. Please call in by 8:00 AM to sign-in. Copies of the meeting agenda will not be provided at the meeting; if you would like a copy please go to the following web address: www.doh.state.fl.us/mqa/massage/ma_meeting.html. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner.

Sincerely,

Samantha Jenkins Regulatory Specialist II BOARD OF MASSAGE THERAPY

Rick Scott Mussmn. (Bu/em Toprded, manna/en's health 0d peopie in Florida througw integrated

stale, cany&oannnflyeffms. Celeste Philip, MD, MPH

HEALTH wwamm Vision: Tobe the Healthist State in the Malian


August 18, 2016 File:84742

To: Zehong Wang 1121 Whitmore St. Unit #a Monterey Park, CA 91755

YOU ARE HEREBY NOTIFIED that the Florida Board of Massage Therapy will consider your application at the following meeting.

Date: September 14, 2016 Time: 9:00 am Type: Conference Call

Meet Me Number: (888)-670-3525 Participation Code: 2597709961

Your participation is not required. However, all respondents are encouraged to participate in the conference call. If you do not participate, the Board may require your appearance at a regularly scheduled Board meeting. Should the Board require your appearance, you will be required to appear at one of the next two regularly scheduled meetings. This may further delay a decision on your licensure. Please call in by 8:00 AM to sign-in.

Copies of the meeting agenda will not be provided at the meeting; if you would like a copy please go to the following web address: www.doh.state.f|.us/mqa/massage/ma_meeting.html.

Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner.

Sincerely,

QM Samantha Jenkins Regulatory Specialist II

BOARD OF MASSAGE THERAPY

4052 Bad W W3“ Bi" 006 ' Td'messee' FL 323993256 Public Health Accreditation Board

Florida Department of Health Wsimof Media OHflymoe' 31d HCPR m Accredited Health Department PHONE (850)2454444- FAX: (850)4122681

P H A B

My name is Zehong Wang,

My email: [email protected]

Massage Therapy Licensing pending application

FILED Department Of Health

Deputy Clerk CLERK offtsce_l cra..cden.A. DATE JUL 2 6 2016

I have currently licensed of professional certified massage therapist with quite a while experiences

in field massage therapy in the state of California, and already graduated with at least 500 hours of

in class of course study as required by Florida for massage therapy. However I still got denied letter

from state of Florida. I would like to request the bard to dispute the material fact of deny decision

and schedule a hearing before an administrative law judge pursuant to section 120.57 (1) Florida

Statutes.

Thank you for your attention on this matter. I would like to have a chance to still obtain the Florida

massage therapy license and hopefully board may give me a fair chance.

Thank you and have a nice day!

FILED Department Of Haalth

My name is Zehong Wang, CLERK Depgy Clerk

. nude“ My email: mmtc9§[email protected]_r_n_ DATE JUL 2 6 2018 Massage Therapy Licensing pending application “.‘ . fl,

I have currently licensed of professional cenified massage therapist with quite a while experiences

in field massage therapy in the state of California, and already graduated with at least 500 hours of

in class of course study as required by Florida for massage therapy. However I still got denied letter

from state of Florida. I would like to request the bard to dispute the material fact of deny decision

and schedule a hearing before an administrative Iawjudge pursuant to section 120.57 (1) Florida

Statutes

Thank you for your attention on this maner. I would like to have a chance ‘0 still obtain the Florida

massage therapy license and hopefully board may give me a fair chance‘

Thank you and have a nice day!

STATE OF FLORIDA BOARD OF MASSAGE THERAPY


Deputy Clerk CLERK cpfx.g.a cf'cutd.n.a. DATE 6-27-2016

IN RE THE APPLICATION FOR LICENSURE OF:

ZEHONG WANG

NOTICE OF INTENT TO DENY

ZEHONG WANG has applied for licensure as a massage therapist. The

application came before the Board of Massage Therapy at a duly-noticed public

meeting on June 8, 2016, by telephone conference call.

The applicant has not established eligibility for licensure pursuant to Section

480.041, Florida Statutes, because she did not demonstrate that she completed a

massage therapy program that meets the minimum standards for training and

curriculum set forth in Rule 64B7-32.003, Florida Administrative Code. The applicant

is deficient 85 classroom hours in basic massage theory and history and 55 classroom

hours in clinical practicum.

Based on the provisions of Sections 456.072(2) and 480.046(2), Florida

Statutes, the Board may deny the application for licensure. It is therefore ORDERED

that the application for certification to be licensed of ZEHONG WANG is hereby

DENIED.

This Order shall become effective upon filing with the Clerk of the Department of

Health.

1


Deputy Clerk CLERK Mel Judah;

STATE OF FLORIDA DATE 6-27-2016

BOARD OF MASSAGE THERAPY "'i


ZEHONG WANG


ZEHONG WANG has applied for Iicensure as a massage therapist. The


meeting on June 8, 2016, by telephone conferenfie call.


480.041, Florida Statutes. because she did not demonstrate that she completed a

massage therapy program that meets the minimum standards fortraining and

curriculum set forth in Rule 6487-32003, Florida Administrative Code. The applicant




Statutes, the Board may deny the application for Iicensure. It is therefore ORDERED

that the application for cenification to be licensed of ZEHONG WANG is hereby

DENIED.


Health.

DONE AND ORDERED this c H day of ( 91/)e,-

, 2016.


a Monroe Executive Director for Lydia Nixon, Chair

NOTICE OF HEARING RIGHTS

You may seek review of this Order, pursuant to Sections 120.569 and 120.57,

Florida Statutes, by filing a petition with the Executive Director of the Board, 4052 Bald

Cypress Way, Bin 006, Tallahassee, Florida 32399-3257, within 21 days of receipt of

this Order. If you dispute any material fact upon which the Board's decision is based,

you may request a hearing before an administrative law judge pursuant to Section

120.57(1), Florida Statutes; your petition must contain the information required by Rule

28-106.201, Florida Administrative Code, including a statement of the material facts

which are in dispute. If you do not dispute any material fact, you may request a

hearing before the Board pursuant to Section 120.57(2), Florida Statutes; your petition

must include the information required by Rule 28-106.301, Florida Administrative Code.

Pursuant to Section 120.573, Florida Statutes, you are hereby notified that

mediation pursuant to that section is not available.

2

DONE AND ORDERED this 0“ day of )UVW .2016.


J/m WWW Manfa Monroel Executive Director for Lydia Nixon, Chair




Cypress Way, Bin C06, Tallahassee, Florida 32399-3257, within 21 days of receipt of

this Order. If you dispute any material fact upon which the Board’s decision is based,

you may request a hearing before an administrative Iawjudge pursuant to Section

120.57(1), Florida Statutes: your petition must contain the information required by Rule

28-1 06.201, Florida Administrative Code, including a statement of the material facts



must include the information required by Rule 28406301, Florida Administrative Code.



CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by certified mail to ZEHONG WANG, 1121 Whitemore Street, Unit A,

Monterey Park CA 91755, and by email to Lee Ann Gustafson, Senior Assistant

Attorney General, LeeAnn.Gustafsonmyfloridalepal.com this atftillay of -3

, 2016.

7016 0340 0000 8263.1968 fl ,V14" ?l00000r kl KRIM

Deputy Agency Clerk

3



fumished by certified mail to ZEHONG WANG, 1121 Whitemore Street, Unit A,


Attorney GeneraI,L LeeAnn. Gustafson m loridale al com this it“ day oft—Sh

. 2016.

Deputy Agency Clerk

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Deputy Clerk CLERK c44asml craft.de.frA

STATE OF FLORIDA DATE 6-27-2016



ZEHONG WANG




meeting on June 8, 2016, by telephone conference call.




curriculum set forth in Rule 64B7-32.003, Florida Administrative Code. The applicant






DENIED.


Health.

1


Deputy Clerk CLERK and and“;

STATE OF FLORIDA DATE 6212016

BOARD OF MASSAGE THERAPY ——————


ZEHONG WANG




meeting on June 8, 2016, by telephone conferenfie call.




curriculum set forth in Rule 6487-32003, Florida Administrative Code. The applicant






DENIED.


Health.

DONE AND ORDERED this O day of , 2016.


kid Ka a Monroe Executive Director for Lydia Nixon, Chair




Cypress Way, Bin C06, Tallahassee, Florida 32399-3257, within 21 days of receipt of

this Order. If you dispute any material fact upon which the Board's decision is based,

you may request a hearing before an administrative law judge pursuant to Section


28-106.201, Florida Administrative Code, including a statement of the material facts



must include the information required by Rule 28-106.301, Florida Administrative Code.



2

(“A /'

DONE AND ORDERED this day of )( 7M , 2016.


a a Monroe Executive Director for Lydia Nixon, Chair




Cypress Way, Bin 006, Tallahassee, Florida 32399-3257, within 21 days of receipt of

this Order. If you dispute any material fact upon which the Board’s decision is based,

you may request a hearing before an administrative Iawjudge pursuant to Section


28-1 06.201, Florida Administrative Code, including a statement of the material facts


hearing before the Board pursuant to Section 120.57(2). Florida Statutes; your petition

must include the information required by Rule 28-1 06.301, Florida Administrative Code.







Attorney General, LeeAnn.Gustafsonawfloridaledal.com this atIty of T.rp , 2016.

7016 0340 0000 8263 1968 Fl s):! s.91 z'14" r -TioDDDDar id PI MRS

Deputy Agency Clerk

3





Attorney General, [email protected] this (3m of EX . 2016.

Deputy Agency Clerk

"RULE [13M] UUUU 521:3 l‘llafi '3 937?: 3""

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FLORIDA |

Board of Massage Therapy APPLICANT WITH CRIMINAL HISTORY

CAI, HONGFANG

DATE OF BIRTH: — FILE NUMBER: 85862 COMPLETION DATE: 08/02/2016

Criminal History



August 11, 2016 File:85862

To: Mrs. Hongfang Cai 2628 Woods Edge Circle Orlando, FL 32817


Sincerely,


[email protected]

Mission : To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts .

Rick Scott Governor

Celeste Philip, MD, MPH Surgeon General and Secretary

Vision : To be the Healthiest State in the Nation

Rick Scott Mission ; Governor To protect, promote & improve the health of all people in Florida through integrated

| t Ph'l' , MD, MPH

state, county & community efforts ‘39 95 e I IP

HEALTH Surgeon General and Secretary

Vision : To be thHealthiest Starethe Nation


August 11, 2016 File:85862

To: Mrs. Hongfang Cai 2628 Woods Edge Circle Orlando, FL 32817





Copies of the meeting agenda will not be provided at the meeting; if you would like a copy please go to the following web address: www.doh.state.fl.us/mqa/massage/ma_meeting.html.



Sincerely,

M Samantha Jenkins Regulatory Specialist II

BOARD OF MASSAGE THERAPY hon fan cai ahoo.com


Florida Depaflment of Health Division of Medical Quality Assurance - Bureau of HCPR Accredited Health Department 40523a|d Cypress Way, Bin COG - Tallahassee, FL 32399-3256 ~ - -

PHONE: (850)245_4444 _ FAX; (850) 4122681 P H A B Pubhc Health Accreditation Board

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons

Scroll down to see the available pages or advance to the next document if all

pages have been removed.

SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS.

456.057 - Ownership and control of patient records; report or copies of records to be furnished.—

10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0100-0199/0119/Sections/0119.07.html

of 5Date Created: Sep 23 2015 1:19PM

Florida Board of Massage TherapyFlorida Department of Health

Initial Application for Licensure

Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts.

Rick Scott Governor

John H. Armstrong, MD, FACS

State Surgeon General & Secretary


Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: MRS. HONGFANG CAIDate of Birth: 03/06/1984Place of Birth: CHINAEmail Address: [email protected]

Basic Data

Mailing Address2628 WOODS EDGE CIRCLE ORLANDO, FL 32817

Physical Location or Address of Employment2628 WOODS EDGE CIRCLE ORLANDO, FL 32817

Phone NumbersHome: 407-274-5869Business:

Equal Opportunity DataGender: FEMALERace: ASIAN/PACIFIC ISLANDER

Education History

School Name: OTHER FLORIDA BOARD APPROVED SCHOOL NOT LISTED

School Name: WORLD OF BEAUTY ACADEMY

School Address:Graduation or Anticipated Graduation Date: 07/23/2015Total Number of Hours Completed: 500

School Name:School Name:School Address:Graduation or Anticipated Graduation Date:Total Number of Hours Completed:

Other Name HistoryNo Other Name History data entered.

Other State LicensesI have never held a license or certificate, regardless of status, to practice any licensed profession.

Apprentice Sponsor InformationName of Sponsor:Total Number of Instructional Hours:

Mandatory Courses at Initial Licensure

Ten hour Florida Laws and Rules CourseI have NOT completed a ten-hour Florida Laws and Rules Course.

Prevention of Medical Errors I have NOT completed a two-hour course in the Prevention of Medical Errors.

M_ _ “V Rick Scan Issmn: \ Governor

To protect, promote, & improve the health L A of all people in Florida through integrated ‘ (it-

. John H. Armstrong MD FACS state, coumy 8‘ community efforts. florlq»fi State Surgeon Gene’ral & éecretary



Florida Board of Massage Therapy

Florida Department of Health

Basic Data Profession: MASSAGE THERAPIST Application Type: INITIAL MASSAGE THERAPIST EXAM APPLICATION Name: MRS. HONGFANG CAI Date of Birth: Place of Birth: CHINA Email Address: [email protected]

Mailing Address 2628 WOODS EDGE CIRCLE ORLANDO, FL 32817

tsical Location or Address of Emplovment 2628 WOODS EDGE CIRCLE ORLANDO, FL 32817

Phone Numbers Home: Business:

407—274—5869

Equal Opportunity Data

Gender: Race:

FEMALE ASIAN/PACIFIC ISLANDER

Education Histom


School Name: WORLD OF BEAUTY ACADEMY

School Address: Graduation or Anticipated Graduation Date: 07/23/2015 Total Number of Hours Completed: 500

School Name: School Name: School Address: Graduation or Anticipated Graduation Date: Total Number of Hours Completed:

Other Name Histozy

No Other Name History data entered.

Other State Licenses I have never held a license or certificate, regardless of status, to practice any licensed profession.

Apprentice Sponsor Information

Name of Sponsor: Total Number of Instructional Hours:


Ten hour Florida Laws and Rules Course

I have NOT completed a ten—hour Florida Laws and Rules Course.

Prevention of Medical Errors I have NOT completed a two—hour course in the Prevention of Medical Errors.

Date Created: Sep 23 2015 1:19PM Page 1 of 5

HIV/AIDS Course

I have NOT completed a three hour HIV/AIDS course.

Electronic Fingerprinting Record exists in the Florida Care Provider Background Screening Clearinghouse and may be eligible for this application requirement.

Acknowledgement Statement I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy, and right to challenge incorrect criminal history records and the "Privacy Statement" document from the Federal Bureau of Investigation. Your answer:

Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense? Your answer:

Discipline Histom

Have you ever been denied the right to take a massage therapy (or any other medical or Your answer: personal service) licensing examination in any state orjurisdiction?

Have you ever been refused a license to practice massage therapy or any other Your answer: professional license — or renewal thereof— in any state or otherjurisdiction?

Have you ever had a license or certificate of registration to practice massage therapy or Your answer: any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in

response to an investigation in any state? (i.e.: Nurse, Chiropractor, Facial/Skin Care Specialist, Physical Therapist, Occupational Therapist etc.)

Are you now or have you ever been a defendant in a civil litigation in which the basis of Your answer: the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?

Is there currently pending against you (in any state orjurisdiction) a complaint against Your answer: your professional conduct or competence?

In the last five years, have you been expelled, suspended from, or had disciplinary action Your answer: taken against you by an educational institution other than your high school?

Date Created: Sep 23 2015 1:19PM

YES

NO

N0

NO

NO

NO

N0

NO

Page 2 of 5

Questions related to Section 456.0635(2). Florida Statutes

Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless Your answer: No of adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state orjurisdiction? For the felonies of the first or second degree, has it been more than 15 years from the Your answer: NIA date of the plea, sentence and completion of any subsequent probation?

For the felonies of the third degree, has it been more than 10 years from the date of the Your answer: N/A plea, sentence and completion of any subsequent probation? (This question does not apply to felonies of the third degree under Section 893.13(6)(a), Florida Statutes).

For the felonies of the third degree under Section 893.13(6)(a), Florida Statutes, has it Your answer: N/A been more than 5 years from the date of the plea, sentence and completion of any subsequent probation?

Have you successfully completed a drug court program that resulted in the plea for the Your answer: N/A felony offense being withdrawn or the charges dismissed?

Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless Your answer: No of adjudication, a felony under 21 U.S.C. 55. 801—970 (relating to controlled substances) or 42 U.S.C. 55. 1395—1396 (relating to public health, welfare, Medicare and Medicaid issues)?

Has it been more than 15 years before the date of application since the sentence and any Your answer: NIA subsequent period of probation for such conviction or plea ended?

Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Your answer: No Section 409.913, Florida Statutes?

If you have been terminated but reinstated, have you been in good standing with the Your answer: N/A Florida Medicaid Program for the most recent five years? Have you ever been terminated for cause, pursuant to the appeals procedures Your answer: NO

established by the state, from any other state Medicaid program?

Have you been in good standing with a state Medicaid program forthe most recent five Your answer: N/A years?

Did the termination occur at least 20 years before the date of this application? Your answer: NIA

Are you currently listed on the United States Department of Health and Human Services Your answer: No Office of Inspector General‘s List of Excluded Individuals and Entities?

On or before July 1, 2009, were you enrolled in an educational or training program in the Your answer: N/A profession in which you are seeking licensure that was recognized by this profession‘s licensing board or the Department of Health?

Additional Information

Availability for Disaster: Will you be available to provide health care services in special Your answer: No needs shelters or help staff disaster medical assistance teams during times of emergency or major disaster?

Email Notification

Would you like to receive electronic correspondence (email)? Your answer: NO

Date Created: Sep 23 2015 1:19PM Page 3 of5

Application Statement

K I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has been submitted if and when any material change in circumstances or conditions occur which might affect the Board‘s decision concerning my eligibility for examination or licensure. Such supplement is required by Section 456.013(1 ), F,S. Failure to do so may result in disciplinary action by the Board including denial of licensure.

I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare that my answers and all statements made by me herein and in support of this application are true and correct. Should I furnish any false information on or in support of this application, I understand that such action shall constitute cause for denial, suspension, or revocation of any license to practice in the state of Florida in the profession for which I am applying. I hereby acknowledge that practice as a licensed Massage Therapist in Florida is governed by Chapters 456 and 480, Florida Statutes, and Rule Chapter 6437, Florida Administrative Code. I

understand that I am under a continuing obligation to understand and keep informed of any changes to Chapters 456 and 480, F.S. and Rule Chapter 6437, Florida Administrative Code.



Rick Scott Governor





www.FloridaHealth.gov TWITTER:HealthyFLA

FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

FLICKR: HealthyFla PINTEREST: HealthyFla

January 21, 2016 Mrs. Hongfang Cai 2628 Woods Edge Circle Orlando, FL 32817

File No. 85862 Dear Applicant: This letter is in reference to your application for massage therapist licensure. Upon initial review, your application has been deemed INCOMPLETE for the following reason(s):

We have not received proof of completion of a three (3) hour HIV/AIDS course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school, Florida Board approved continuing education provider, or the American Red Cross. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. We have not received a passing score directly from the Federation of State Massage Therapy Boards (FSMTB). Please contact the FSMTB and have them release your score to our office. They may be reached at 1-866-962-3926 or at www.fsmtb.org. We have not received proof of completion of a two (2) hour prevention of medical errors course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. The background screening results received show COMMUNICATING A THREAT from 09/23/2014 that was not disclosed on the application. Please provide the below documentation. (1.) A self-explanation describing the details of your criminal history written in your own words. If it is determined that your application must appear before the Board, this is what the Board will read. (2.) Documentation from the Clerk of Court in the county the offense occurred pertaining to the charge. This should include any arrest documentation, disposition of each charge and proof of successful completion of sentencing. We have not received an official transcript containing the school seal, on counterfeit-proof

Rick Scott Mussmn:

Governor To prdeci, pmue & imam/e the hath of all peopie in Florida through integrated

stale, & flyeffofls. John H. Armstrong, MD, FACS

HEALTH SialeSrgemGereraI &Seaetary

Vision: Tobe the Healthiest State in the [Him

January 21, 2016

Mrs. Hongfang Cai 2628 Woods Edge Circle Orlando, FL 32817

File No. 85862

Dear Applicant:

This letter is in reference to your application for massage therapist licensure. Upon initial review, your application has been deemed INCOMPLETE for the following reason(s):

We have not received proof of completion of a three (3) hour HIV/AIDS course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school, Florida Board approved continuing education provider, or the American Red Cross. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

We have not received a passing score directly from the Federation of State Massage Therapy Boards (FSMTB). Please contact the FSMTB and have them release your score to our office. They may be reached at 1-866-962-3926 or at www.fsmtb.org.

We have not received proof of completion of a two (2) hour prevention of medical errors course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

The background screening results received sho rom 09/23/2014 that was not disclosed on the application. Please provide the below documentation.

(1 .) A self-explanation describing the details of your criminal history written in your own words. If it is determined that your application must appear before the Board, this is what the Board will read.

(2.) Documentation from the Clerk of Court in the county the offense occurred pertaining to the charge. This should include any arrest documentation, disposition of each charge and proof of successful completion of sentencing.

We have not received an official transcript containing the school seal, on counterfeit-proof

www.FloridaHealIh.gov Florida Department of Health TWITI'ERHathyFLA Dvision of Nbdcd Qafly Woe - Bjrmu of HCPR FACEBOOK FLDepa'mmofl-mlth 4052 dO/pwmby, BinCXB- ldwfiee, FL323993256 YOUTLBE: fidoh Pi-KWE (850)2454444 - FAX: (850)4122681 FLICKR Han/Fla

P1NTEREST: Han/Fla

paper, mailed directly from a massage therapy school. The school must be approved by the equivalent State licensing agency or State Department of Education in which it is located.

We have not received proof of completion of a ten (10) hour Florida laws and rules course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department.

You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/m aservices/lo in.as Once there, select your profession and enter your usernamHto check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow ’10 working days for the processing of this documentation.

If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,

Samantha Jenkins OPS Regulatory Specialist II

FLORIDA |

Board of Massage Therapy APPLICANT WITH DISCIPLINARY HISTORY

CUI, HAIYUE DATE OF BIRTH: — FILE NUMBER: 88361 COMPLETION DATE: 05/18/2016

Education History School approved by New Jersey Department of Labor and Workforce Development

Disciplinary History **APPLICANT DID NOT DISCLOSE THE FOLLOWING DISCIPLINARY HISTORY ON

INITIAL APPLICATION“

Previous License: MA56783 Case Number: 2010-20583 Date of Final Order: May 4, 2012 License Status: REPRIMANDED, REVOKED

Report prepared by Gerry Nielsen


Rick Scott Governor





FLORIDA BOARD OF MASSAGE THERAPY - NOTICE OF HEARING

August 11, 2016 File:88361

To: Haiyue Cui

3425 146th St 2nd Fl Flushing, NY 11354


Sincerely, Gerry Nielsen Regulatory Specialist II BOARD OF MASSAGE THERAPY

Rick Scott Mission: To protect, prmme&inm/emehealm

,

Gwemor

gmgmwu‘ffiééegmd ‘ Celeste Philip, MD, MPH ’ '

HEALTH 3‘99” Gaee‘meae'ay

Vision: Tobe the Healthiest State in the Malian


August 11, 2016 File:88361

To: Haiyue Cui 3425146th St 2nd Fl Flushing, NY 11354








Sincerely,

1

Gerry Nielsén Regulatory Specialist II


4°52 BeldO/pmsWay, Binme' Td'messee' FLm3256 H A B Public Health Accreditation Board

Florida Department of Health Wsim of Nbdia! Qfilflymme ' W of HCPR m Accredited Health Department PHOIE (850)2454444 - FAX: (850)4122681

P

of 5Date Created: May 17 2016 7:07PM




Rick Scott Governor


Interim State Surgeon General


Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: HAIYUE CUIDate of Birth: 06/25/1965Place of Birth: CHINAEmail Address: [email protected]

Basic Data

Mailing Address3425 146TH ST 2ND FL FLUSHING, NY 11354

Physical Location or Address of Employment3425 146TH ST 2ND FL FLUSHING, NY 11354



Education History

School Name: OTHERSchool Name: AMERICAN TRAINING

SCHOOLSchool Address: WEST NEW YORK, NJGraduation or Anticipated Graduation Date: 03/20/2009Total Number of Hours Completed: 768






Ten hour Florida Laws and Rules CourseI have completed a ten-hour Florida Laws and Rules Course.

Date Completed: 05/17/2016Course Name/Title: 1174806 FL 10 HOUR LAW COURSE

Provider Number: FL 50-2554-4Provider/School Name: CEUONLINE

Prevention of Medical Errors

Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. a

g.Q 19"


Rick Scott Governor

Celeste Philip, MD, MPH Interim State Surgeon General

M Profession: Application Type: Name: Date of Birth: Place of Birth: Email Address:

Mailing Address 3425 146TH ST 2ND FL FLUSHING, NY 11354




MASSAGE THERAPIST INITIAL MASSAGE THERAPIST EXAM APPLICATION HAIYUE CUI— CHINA [email protected]

tsical Location or Address of Emplovment 3425 146TH ST 2ND FL FLUSHING, NY 11354



Gender: Race:

Education Histom

973—666—6789


School Address: Graduation or Anticipated

WEST NEW YORK, NJ

Graduation Date: 03/20/2009 Total Number of Hours Completed: 768

School Name: OTHER School Name: School Name: AMERICAN TRAINING School Name:

SCHOOL School Address: Graduation or Anticipated Graduation Date: Total Number of Hours Completed:

Other Name Histom





Mandatorv Courses at Initial Licensure


I have completed a ten—hour Florida Laws and Rules Course.

FL 50—2554—4

CEUONLINE Provider Number: Provider/School Name: Course Name/Title: Date Completed: 05/17/2016


Date Created: May 17 2016 7:07PM

1174806 FL 10 HOUR LAW COURSE

Page 1 of 5

I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B7—25.001(1)(f), F.A.C. Provider Number: 20—154894 Provider/School Name: CE FOR HEALTH CARE PROFESSIONALS Course Name/Title: PREVENTION OF MEDICAL ERRORS Date Completed: 05/17/2016

HIV/AIDS Course

I have completed a three hour HIV/AIDS course.

Provider Number: 50—620 Provider/School Name: EXCELLENCE IN LEARNING Course Name/Title: 100 HIV AIDS FOR INITIAL FL LICENSURE OR ENDORSEMENT Date Completed: 05/17/2016

Electronic Fingerprinting The Florida Care Provider Background Screening Clearinghouse does not have a record at this time.

Acknowledgement Statement I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy, and right to challenge incorrect criminal history records and the "Privacy Statement" document from the Federal Bureau of Investigation. Your answer: YES

Criminal Histogy

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Your answer: YES

Discipline HistoLy

Have you ever been denied the right to take a massage therapy (or any other medical or Your answer: NO

personal service) licensing examination in any state orjurisdiction?

Have you ever been refused a license to practice massage therapy or any other Your answer: No professional license — or renewal thereof— in any state or otherjurisdiction?

Have you ever had a license or certificate of registration to practice massage therapy or Your answer: YES

any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in


Are you now or have you ever been a defendant in a civil litigation in which the basis of Your answer: NO the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?

Is there currently pending against you (in any state orjurisdiction) a complaint against Your answer: NO

your professional conduct or competence?

In the last five years, have you been expelled, suspended from, or had disciplinary action Your answer: No taken against you by an educational institution other than your high school?

Date Created: May 17 2016 7:07PM Page 2 of5









If you have been terminated but reinstated, have you been in good standing with the Your answer: N/A Florida Medicaid Program for the most recent five years? Have you ever been terminated for cause, pursuant to the appeals procedures Your answer: N0 established by the state, from any other state Medicaid program?






Availability for Disaster: Will you be available to provide health care services in special Your answer: YES needs shelters or help staff disaster medical assistance teams during times of emergency or major disaster?

Email Notification

Would you like to receive electronic correspondence (email)? Your answer: YES


DEPARTMENT OF HEALTH,

Petitioner,

vs.

HAI YUE CUI,

Respondent.

Case No.: 2010-20563 License No.: MA 56763


Final Order No. DOH- 12-0832-r0 I -MQA FILED DA1 Am, O 8 Z012

Departinc

k611— uty Agency Clerk

FINAL ORDER

This matter appeared before the Board of MASSAGE THERAPY at

a duly-noticed public meeting on April 19, 2012 in Tampa,

Florida, for a hearing not involving disputed issues of material

fact pursuant to Sections 120.569 and 120.57(2), Florida

Statutes. Petitioner has filed an Administrative Complaint

seeking disciplinary action against the license. A copy of the

Administrative Complaint is attached to and made a part of this

Final Order. Service of the Administrative Complaint was made

upon Respondent by publication. Respondent has not filed an

Election of Rights. Petitioner has filed a Motion for

Determination of Waiver and Entry of Final Order. Petitioner was

represented by S. J. DiConcilio, Assistant General Counsel,

Florida Department of Health. Respondent was not present.

FINDINGS OF FACT

Since the licensee has not replied to the Administrative

Complaint nor contested the factual allegations, the prosecuting

Case No. 2010 -20593 1

Final Order No. DOH- [2-0832-[6 l -MQA FILED DAT]

49L.“ 8 2012 A Deparuu

STATE OF FLORIDAB BOARD OF MASSAGE THERAPY

utyAgencyClerk DEPARTMENT OF HEALTH,

Petitioner, vs.

Case No.: 2010—20565 License No.: MA 56763 HAI YUE CUI,

Respondent.

/ FINAL ORDER

This matter appeared before the Board of MASSAGE THERAPY at a duly—noticed public meeting on April 19, 2012 in Tampa, Florida, for a hearing not involving disputed issues of material fact pursuant to Sections 120.569 and 120.57(2), Florida Statutes. Petitioner has filed an Administrative Complaint seeking disciplinary action against the license. A copy of the Administrative Complaint is attached to and made a part of this Final Order. Service of the Administrative Complaint was made upon Respondent by publication. Respondent has not filed an Election of Rights. Petitioner has filed a Motion for Determination of Waiver and Entry of Final Order. Petitioner was represented by S. J. DiConcilio, Assistant General Counsel, Florida Department of Health. Respondent was not present.

FINDINGS OF FACT

Since the licensee has not replied to the Administrative Complaint nor contested the factual allegations, the prosecuting

1 Case No. 2010-20593

attorney offered the investigative file to prove the facts as

alleged. The investigative file was received into evidence and

the Board finds the uncontested facts adequately support the

allegations. Therefore, the Board adopts as its finding of facts

the facts set forth in the Administrative Complaint. In

aggravation of the penalty to be imposed, the Board finds that

the crime to which Respondent entered a plea was related to

prostitution.

CONCLUSIONS OF LAW

Based upon the Findings of Fact, the Board concludes the

licensee has violated Section 480.046(1)(c) and (o) and

456.072(1)(x), Florida Statutes.

The Board is empowered by Sections 480.046(2) and

456.072(2), Florida Statutes, to impose a penalty against the

licensee. Therefore it is ORDERED that:

The license of HAI YUE CUI is hereby REPRIMANDED.

The license of HAI YUE CUI is REVOKED.

This Final Order shall become effective upon filing with the

Clerk of the Department of Health.

DONE AND ORDERED this ei day of BOARD MASSAGE TH

"Cr , -411110P/

,41110r4410 Anthor Ju;- itch Exec f ive 'irector for Kar: Goff Ford, CHAIR

2

, 2012.

Case No. 2010 - 20593

attorney offered the investigative file to prove the facts as alleged. The investigative file was received into evidence and the Board finds the uncontested facts adequately support the allegations. Therefore, the Board adopts as its finding of facts the facts set forth in the Administrative Complaint. In aggravation of the penalty to be imposed, the Board finds that the crime to which Respondent entered a plea was related to prostitution.

CONCLUSIONS OF LAW

Based upon the Findings of Fact, the Board concludes the licensee has violated Section 480.046(l)(c) and (o) and

456.072(l)(x), Florida Statutes. The Board is empowered by Sections 480.046(2) and

456.072(2), Florida Statutes, to impose a penalty against the licensee. Therefore it is ORDERED that:

The license of HAI YUE CUI is hereby REPRIMANDED.

The license of HAI YUE GUI is REVOKED.

This Final Order shall become effective upon filing with the Clerk of the Department of Health.

DONE AND ORDERED this 5! day of , 2012.

BOARD MASSAGE TH

itch irector for

Goff Ford, CHAIR

Case No. 2010-20593

aay of

NOTICE OF APPEAL RIGHTS

Pursuant to Section 120.569, Florida Statutes, the parties

are hereby notified that they may appeal this Final Order by

filing one copy of a notice of appeal with the clerk of the

department and by filing a filing fee and one copy of a notice of

appeal with the District Court of Appeal within thirty days of

the date this Final Order is filed.


I HEREBY CERTIFY that a true and correct copy of the

foregoing has been furnished by Certified U.S. Mail to HAI YUE

CUI, 34-25 146 th Street, Flushing NY 11354 & 33-37 Parsons Blvd

#3F, Flushing NY 11354; by interoffice mail to Lee Ann Gustafson,

Assistant Attorney General, PL-01, The Capitol, Tallahassee,

Florida 32399-1050; and S. J. DiConcilio, Assistant General

Counsel, Department of Health, 4052 Bald Cypress Way, Bin # C-65,

Tallahassee, Florida 32399-3265 on this

2012.

#436eYt9 Sicod044,

Deputy Agency Clerk

41 25 IL40- ‘ Vi)arafiAS 7011 2970 0003 1594 2384 3

7011 2970 0003 1594 4210

NOTICE OF APPEAL RIGHTS

Pursuant to Section 120.569, Florida Statutes, the parties are hereby notified that they may appeal this Final Order by filing one copy of a notice of appeal with the clerk of the department and by filing a filing fee and one copy of a notice of appeal with the District Court of Appeal within thirty days of the date this Final Order is filed.


I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by Certified U.S. Mail to HAI YUE

CUI, 34—25 146th Street, Flushing NY 11354 & 33—37 Parsons Blvd #3F, Flushing NY 11354; by interoffice mail to Lee Ann Gustafson, Assistant Attorney General, PL—Ol, The Capitol, Tallahassee, Florida 32399—1050; and S. J. DiConcilio, Assistant General Counsel, Department of Health, 4052 Bald Cypress Way, Bin # C—65,

- 'xv Tallahassee, Florida 32399—3265 on this fjéy of I!!! 54 } 2012.

Deputy Agency Clerk

34.25 MM“ 3+ 33.3r7 Wang 15W, CHEBF

7Dll EH?D DUDE IEHH HEIU \ ~—

?Dll EH?D DUDE ISHH 2364

STATE OF FLORIDA DEPARTMENT OF HEALTH


PETITIONER,

v. CASE NO. 2010-20583

HAI YUE CUI, LMT,

RESPONDENT.

DIvAALIn COMPLAINT

COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the

Board of Massage Therapy against Respondent, Hai Yue Cui, LMT, and in

support thereof alleges:

1. Petitioner is the state department charged with regulating the

practice of occupational therapy pursuant to Section 20.43, Florida

Statutes; Chapter 456, Florida Statutes; and Chapter 480, Florida Statutes.

2. At all times material to this Complaint, Respondent was a

licensed massage therapist within the state of Florida, having been issued

license number MA 56763, on or about August 6, 2009.

I K: \ShahMX\Massage Therapy\Kai Cul - Sexual Mlsconduct\AC.doc

261

STATE OF FLORIDA ,

DEPARTMENT OF HEALTH


PETITIONER,

v.

’

CASE NO. 2010-20583 'HAI YUE cur, LMT,

RESPONDENT.

' DMI I TIV C M INT

COMES NOW, Petitioner, Department of Health, by and through its undersigned counsel, and files this Administrative Complaint before the Board of Massage Therapy against Respondent, Hai Yue Cui, LMT, and in support thereof alleges:

1. Petitioner is the state department charged with regulating the practice of occupational therapy pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 480, Florida Statutes.

2. At all times material to this Complaint, Respondent was a licensed massage therapist within the state of Florida, having been 'issued

. license number MA 56763, on or about August 6, 2009.

l K:\ShahMX\Massage Thelap‘AHai Cui ~ Sexual MlsmnducflAfidoc

_261I

3. Respondent's address of record is 33-37 Parsons Blvd., #3F,

Flushing, New York 11354.

4. However, an Accurint search reveals that Respondent's last

known address is 3715 Parsons Blvd., Apt. 6B, Flushing, New York 11354.

5. At all times material to this Complaint, Respondent practiced

massage therapy at Aja Health Spa, which is located at 2636 University

Blvd. West, Jacksonville, Florida 32217.

6. On or about October 19, 2010, an undercover officer from the

Jacksonville Sheriff's Office visited Aja Health Spa.

7. The undercover officer paid eighty dollars ($80.00) in United

States currency with a twenty dollar ($20.00) tip for an hour massage.

8. During the massage, Respondent agreed to masturbate the

undercover officer, whereupon Respondent was arrested and transported

to the Jacksonville Sheriff's Office.

9. On or about October 20, 2010, Respondent entered a plea of

nob contendere.to the charge of offering or engaging in prostitution in the

County Court of Duval County, Florida, in case number 16-2010-MM-20386.

2 hahMX‘Massage TherapMai Cui - Sexual Misconduct\AC.doc

262 262

3. Respondent’s address of record is 33-37 Parsons Blvd., #3F, Flushing, New York 11354.

_

4. However, an Accurint search reveals that Respondent's last knOWn address is 3715 Parsons Blvd., Apt. 68, Flushing, New York 11334.

5. At all times materiaf to this Complaint, Respondefit practiced massage therapy at Aja Health Spa, which is located at 2636’ University Blvd. West, Jacksonville, Florida 32217.

6. On or about October 19, 2010, an undercover officer from the Jacksonville Sheriff’s Office visited Aja Health Spa.

7. The undercover officer paid eighty dollars ($80.00) in United States currency with a twenty dollar ($20.00) tlp for an hour massage.

8. During the massage, Respondent agreed to masturbate the undercover officer, whereupon Respondent was arrested and transported to the Jacksonville Sheriff's Office.

9. On or about October 20, 2010, Respondent entered a pleé of nolo contendereto the charge of offering or engaging in prostitution in the County Court of Duval County, Florida, in case number 16-2010—MM-20386.

2 Ic\5hahMX\Massage Th'erapy\Hal Cui - Sexual Miscondutcmc ‘4 r4“;

10. Pursuant to Respondent's nob contendere plea in the County

Court of Duval County, Florida, on October 20, 2010, adjudication was

withheld and she was ordered to pay fines and costs.

11. As of December 30, 2010, pursuant to correspondence received

from the Massage Therapy Board Office, Respondent has not notified the

Board Office of her nolo contendere plea entered on October 20, 2010, in

the County Court of Duval County, Florida.

fg2arn

12. Petitioner realleges and incorporates paragraphs one (1)

through eleven (11), as if fully copied herein.

13. Section 480.046(1)(c), Florida Statutes (2009), provides that

being convicted or found guilty, regardless of adjudication, of a crime in

any jurisdiction which directly relates to the practice of massage or to the

ability to practice massage therapy, constitutes grounds for disciplinary

action by the Board of Massage Therapy.

14. When Respondent entered a nolo contendere plea on October

20, 2010, she pled to the crime of offering or engaging in prostitution,.

which was committed while providing a massage therapy treatment to an

undercover officer on October 19, 2010.

3 K: hahMX\Massage TheramMal Cui - Sexual Misconduct\AC.doc

263

10. Pursuant to Respondent’s nolo contendere plea in the County Court of Duval County, Florida, on October 20, 2010, adjudication Was

withheld and she was ordered to pay fines and costs.

11. As of December 30, 2010, pursuant to correspondence received from the Massage Therapy Board Office, Respondent has not notified the Board Office of her noio contendere plea entered on October 20, 2010, in

. the County Court of Duval County, Florida. '

9.9mm 12. Petitioner realleges

'

and_ incorporates paragraphs one (1) through eleven (11), as if fully copied herein.

I

‘

13. Section 480.046(1)(c), Florida Statutes (2009), provides that being convicted or found guilty, regardless of adjudication, of a crime ,In

any jurisdiction which directly relates to the practice of massage or to the ability to practice massage therapy, constitutes grounds for disciplinary action by the Board of Massage Therapy.

14. When Respondent entered a nolo contendere plea on October 20, 2010, she pléd to the crime of offerlng or engaglng in prostimtlon,. which was committed while providing a massage therapy treatment to an

undercover officer on October 19, 2010.

3 K:\ShahMX\Massage Therav-Ial Cui — Sew-I Mismnductucdoc

15. Based on the foregoing, Respondent violated Section

480.046(1)(c), Florida Statutes (2009).

COUNT II

16. Petitioner realleges and incorporates paragraphs one (1)


17. Sectioh 480.046(1)(o), Florida Statutes (2009), provides that

violating any provision of this chapter or chapter 456, or any rules adopted

pursuant thereto, constitutes grounds for disciplinary action by the Board

of Massage Therapy.

18. Section 456.072(1)(x), Florida Statutes (2009), provides that

failing to report to the board, or the department if there is no board, in

writing within 30 days after the licensee has been convicted or found guilty

of, or entered a plea of nolo contendere to, regardless of adjudication, a

crime in any jurisdiction.

19. As of December 30, 2010, Respondent has failed to report to

the Board of Massage Therapy that she entered a plea of nolo contendere

to the crime of offering or engaging in prostitution on October 20, 2010, in

the County Court of Duval County, Florida, in case number 16-2010-MM-

20386.

4 K: hahMX\Massage Therapy\Hai Cui - Sexual Misconduct\AC.doc

264 264


480.046(1)(c), Florida Statutes (2009).

- 9M1! 16. Petitioner reafleges and incorporates paragraphs one (1)


17. Sectio'n 480.046(1)(o), Florida Statutes (2009), I

firovides that violating any provision of this chapter or chapter 456, or any rules adopted pursuant thereto, constitutes grounds for disciplinary action by the Board

. of' Massage Therapy.

18. Section 456.072(1)(x), Florida Statutes (2009), provides that failing to report to the board, or the department if there is no board, in writing within 30 days after the licensee has been convicted or found gul‘lty

of, ,or'entered a plea' of nolo contendere to, regardless of adjudication, a

crime in any jurisdiction..

19. As of December 30, 2010, Respondent has failed to report to the Board of Massage Therapy that she entered a plea of nolo contendere to the crime of offering or engaging in prostithtion on [October 20, 2010, in the County Court of Duval County, Florida, in case number 16-2010-MM—

20386.

4 K2\5hahMX\Massage Thempflflai Cui - Sexual Misconducmcanc“M

20. Based on the foregoing, Respondent violated Sections

480.046(1)(o) and 456.072(1)(x), Florida Statutes (2009).

WHEREFORE, Petitioner respectfully requests that the Board of

Massage Therapy to enter an order imposing one or more of the following

penalties: permanent revocation or suspension of Respondent's license,

restriction of practice, imposition of an administrative fine, issuance of a

reprimand, placement of Respondent on probation, corrective action,

refund of fees billed or collected, remedial education and/or any other relief

that the Board deems appropriate.

SIGNED this 7th day of Am 2011.

H. Frank Farmer, Jr., M.D., Ph.D. State Surgeon General

Manshi Shah, Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 65520 (850) 245-4640 ext. 8133 (850) 245-4684 FAX

FILED DEPARTMENT OF HEALTH

DEPUTY CLERK

C LERK 6,krabog. 55:4 DATE APR 0 8 2011

PCP: April 7, 2011 PCP Members: Karen Harrison & William Stoehs

5 PSU\Ailied Health\ShaMMassage "therapyVial Cul - Sexual Misconduct \A.C.doc

265

20. Based on the foregoing, Respondent violated Sections 480.046(1)(o) and 456.072(1)(x), Florida Statutes (2009).

WHEREFORE, Petitioner respectfully requesB that the Board of Massage Therapy to enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent’s license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriaé.

SIGNED this 3 day ofAm 2011.

'H. Frank Farmer, Jr., M.D., Ph.D. State Surgeon GeneralW Manshi Shah, Assistant General Counsel DOH Prosecution Services Unit “LE“ 4052 Bald Cypress Way Bin C-65 TH

I “"3354'5855'3“ ' '

Tallahassee, FL 3399-3265 CLERK SM» 5% -

Florida Bar # 65520 DATE APR 0 s 20” > (850) 245-4640 ext. 8133

(850) 245-4684 FAX

PCP: April 7, 201,1 PCP Members: Karen Harrison & \Mlliam Stoehs

5 J:\PSUWlied HealtMShahWasage TherwyWal Cu! - Samal MlsconductMCAcc

265

Hai Yue Cul-- DOH Case No.: 2010-20583

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested.

NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

6 PSUWlied Health\Shah \Massage TherapAlial Cui - Sexual MisconductAC-cloc

266

Hal Yue Cui— DOH Case No.: 2010-20583

NOTICE or RIGHTS

Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine Witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in additionvto 'any other disclpline imposed.

6 J:\PSU\NIied HealtMShahWassage Therapy\Hai Cui - Sexual Misconducmcnoc

My Commission Expires:,

AFFIDAVIT

A-Ne I%nde , Deputy Clerk for the Department

Clerk's Office, hereby certify in my official capacity as custodian for the

Department Clerk's records, that the Department Clerk's Office has not

received an Election of Rights form or other responsive pleading, which

requests a hearing prior to any Department action regarding HAI YUE

CUI, Case Number 2010-20583 which would affect the Respondent's

substantial interests or rights.

fArsce SattdpA4 Custodian of Records Department Clerk's Office

Before me, personally appeared 411( I arlder_s , whose

identity is known to me by OIL (type of identification) and

who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this 21;1 4* day of

Feb . 2012.

RENADA CONLEY Commission DD 818579 Expires November 9, 2012 Bonded Thru Troy Fain Insurance 800-385-7019

AFFIDAVIT

I, We\ \Qfiflde (3 , Deputy Clerk for the Department

Clerk’s Office, hereby certify in my official capacity as custodian for the

Department Clerk’s records, that the Department Clerk’s Office has not

received an Election of Rights form or other responsive pleading, which

requests a hearing prior to any Department action regarding HAI YUE

C I Casé Number 2010-20583 which would affect the Respondent’s

substantial interests or rights.

Custodian of Records Department Clerk’s Office

Before me, personally appeared QHFI glfidfl/S , whose

identity is known to me by EIV— (type of identification) and

who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this 28:11 day of

b- 2,0.12

@330d RENADA CONLEY Commission DD 818579 Expires November9 2012 5W 4‘3a aVO’yF! lmlmOO-WME

My Commission Expires:

Massage Thetapy Application Checklist . , Incomplete Lefier Sent: Do’re File Complete: Date Ucense Issued:

Histog Agglicant Date to History Committee: Dme of History Comm Rec: Date to PRN:

Board Meeting Date:

5205 Fee lecelved

All Questions Answered

Social Security Number Plovided

Ailioovn Signec

Photo Afloched

Check COMPN for Previous License & Complaints

ll Yes. License I? (pull microfilm)

S’rote License Verif. Recelved? 1’ Name Change Docs Received?

CSmpl'e’f‘ed

150 Anatomy/Physiology 225 Msg Theory/Prod 97 Allied Modalities l5 Hydrotherapy 10 Lows/Rules 3 HIV/AIDS

. 2 Medical Errors

coco-o Wm Dates of A'n‘endcnce or Cerfificote

indicohm some?

/ W5? No

Seal and Signature? MONO " .' Afiétéfifijg‘éj’sfiiflfigdfiififiei Received! “was

cé'nipleted ,: :

Apprenticeship Completed? DVels W Ri661'b12NCBTMB Ear—W239; “lama” '

-— Diafi‘éieficyopdtb mafia» ,3» ,{f Passing Score Received? Yes E] No *\

'; ‘A;Hisrory: lnformufionfifim 55%;»: :Réc'elved'é; £1339 KM» Deflblency' a: Date. MEI}?-

Chalges: . Self Explanation D Yes D No . Charge Documents C] Yes CI No . Disposlfion Info. C] Yes Cl No

Plevious Impairment/Addiction: . Self Explancflon (including a list [1 Yes Cl No

of all docs/ptogxonmlmeds) - Lefler from ALL doctors/ D Yes C] No

programs Plevious Discipline/Rehasal/Deniul:

. Sen Explanation D Yes CI No - Official Documents 13 Yes [I] No . Outcome/Ordet E] Yes I] No

Expulsion/Fired: . Self Explanation [:1 Yes D No

Do Not Wn'te In This Space Office Use Only

HEAL! ~ F 750142 5‘ Massageg‘i‘ei'ffimp'i‘m"

State Of Florida Application for Massage Therapist Licensure

FLORIDA DDAKl’MENl' OF

05/ 15/ 2009 205.00 Board of Massage Therapy . .,.

PO BOX 6330 ID- 59425 |

Tallahassee, Florida 32399-5330 BI: 3010603 (850) 488-0595

UL: 908089601 1. Select Appllcation Category:

I

[X] Lioensure by Exam I] Licensuve by Endorsement _ 2. Would you be willing to provide health services in special needs shelters or to help staff disaster 8 Yes D N0 medical assistance teams during times of emergen or major disasters? 3. Name: {Flm’ (MiddlelnIHal) (L83!) 9

H A 1 V0 8 C u\ 4. Social Secunty Number (Requlred):

5. Mailing Address: (Street number 3. Ram) . »

L»,

9,9; ~ 37 Pawns ,8q 74’: 5%: b

(any , sm 3 Zip Code) I I ‘ 2‘ ‘33"

fwd/Lug, My // 2 57% — g ‘- Physlcal Address (50w number!- Mams) I r w : 5W “3 aid/e g 3 (any , seats a zip Coda]

'-‘-’ E 7. Phone Numbers: (Notom Number) (3/7 ) {(PZA D 735? r __‘

(Bullies: Phone Number) Aug/(l6

8. Have you ever changed your name through marriagé or through acfion of a court. D Yes RN!) or have you ever been known by any other name?

If yesLlist name(s) and date(s) of name change(s):

9. We are requimd lo ask that you furnish the fullawing Wonnafion as pan of your voluntary complianw with Sean" 2. Uniform Guhefines on Employee Seledlon Procedure (1978) 43 FR38296 (August 25, 1978), This Information Is gameved cor stailsfical and reporting pumosas any and m not in any way affect your andidacy for “censure.

Place 073w: (csm-zICou-my): \ Sex: Female Male

.4 T I 1 A . Ln A4 Race And National Origin Caua: ian Hispanic

E] Native American [3 Black IXOrienlal C] Other.

Physical Description: (COW {if I (6010' 0' H M ( , M) Ma's?!” gym A, f, c g —3 LLO om" Means m ldanflfnzadon) (unwrs License Number)

(:1 6 6 U! 10. Are you a cifizen of Me United States? - a. If you answered no, which Coumy do you hold citizenshie to? m ‘V\"\_ D Yes 31 N°

11. Have you ever been in the United Sta‘es Mil‘nary or Public Health Service? [:I Yes 18 No a. If 'yes' list branch of service. rank and dams 01 service: I). Have charges ever been brought against you by any branch of the United States Armed Services? [:I Yes ENG

If yes. please refs! to applicahbn inslmdions for required dowmsnlelion. DH-MQA1115, 11/07

12. Do you now hold or have you ever held any license (medial or ptofessional service) or certificate of registration to practice massage thermal or any other grofess‘von, in any state, U8 I] Yes Km territory or foreign country? (9.9; Nursing. Chiropractic. Facial and Skin Cam Spadallsl. Physical Thaapist‘ Oowpatianal merapllsc etc.)

a. If yes, list state(s), TYPE of license, license number(s), date(s) of issuance, status of Iioense(s) and an explanation if the license is no longer active:

13. Massage Therapy Diploma or certificate was obtained from: ' 00 n kinda

Is this a Florida Board Approved School? E] Yes No

Dates Attended: oéAOZJ—oog v‘ 21 2 (39°? Total Number of Hours Compteted: f 2 é 8 H

'

b c: l n 14. If you attended an Apprenticeship program: 3 ‘1;

Name of Sponsor: No N a

- D m Total Number of Instruction Hours Completed: ‘3

m > APPLICANT HISTORY , .

Please be advised that failure by the applicant to provide the suppom‘ng documemafion and informalion, at mkfimefie application is: filed. could lead '0 a delay in the pmcessing of the application, including but not limited to a masked c: appearance before the Board. referral to PRN or any other measure authorized by law. 1H!

PROFESSIONAL LICENSURE :- If you answer 'yes” to any of questions 15-19 below, you must provide the following WITH the application a! the time o! submission:

1. A statement explaining in your own words the complete details as (a the state(s). license numbeds) and relevant circumstances.

2. A copy of all documentation from the sta!e{s) regarding the incident, including the complaint and final action.

15‘ Have you ever been denied the righ! to take a massage therapy (or any other medial or D Yes a No personal service) licensing examination in any state or juris‘flction

16. Have you ever been refused a license to practice massage therapy 0: any other professional D Yes IZ N0 license - or renewal thereof- in any state or other jurisdidion?

17. Have you ever had a license or certificate of registration (0 practice massage therapy or any o‘her licensed profession revoked. suspended or otherwise acted against (including pmbafion, fine, D Yes BN0 reprimand, or surrender of a license) in a disciplinary proceeding or in response to an invesfigafion in any state? (la; Nurse, Chiropmdut. FaunvSkin Care Spea‘allsl. Physial Mania. Oeumafional Thataplsl etc.)

18. Are you now or have you ever been a defendant in a civil litigation in which the basis of the complaint against you was an alleged negligence. malpractice, or lack of professional competence, [:1 Yes {3 No or sexual miscondud?

19. Is there currently pending against you (in any state or jurisdiction) a complaim against your D Yes 8 No professional conduct or competence?

CRIMINAL HISTORY If you answer “yes” to question 20 below, you mus! provide the following WITH the application at the time of submission:

1. Completion of the attached Criminal History Fonn, on which you must provide all relevant details. 2. Certified documentation from the Clerk of Com? pertaining to the arrest/charges, sentencing due to the arrest

anQproof of successful completion of your sentencing. 20. Have you ever been convicted of. or entered a plea of guilty. nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies. even if the coun withheld adjudication so thai you would not have a record 01 conviction. E] Yes BNO dlng under the Influence or driving whlle Impaired Is not a minor traffic offense for purposes ofthls question.

6

EDUCATION HISTORY If you answer "yes' to question 25 below, you must submit the following WITH your application a! the time a! submission:

1. A statement indicating the details surrounding the instance, including the institution name and add/ass and dates.

2. A statement from the institution regarding the incident and outcome

25. In the last five years, have you been expelled. suspended from. or had disciplinary action taken [3 Yes [3 No against you by an educational institution other than your high school?

>

L—J L; “DU? 3 —I.

AFFIDAVIT 0F APPUCATNT; I, H pd #0 e C U» affirm that I am the perfi) refegd to in the foregoing massage men-apy Iioensuré appliwfion. and that the attached photograph is a true likeness of myse". __ .v

CD I) I understand that it is my duty and responsibility as an appliwnt for licensure to suppiemenl my appficafion afler R has been submméd If and when any material change in dreumsunoes or conditions occur whim might affed the Board‘s decision concerning "$39“: for examination or licensura. Such supplement is required by Chapter 456.0130). F,S. Failure to do so may result in disdpli a by the Board induding denial of Iioensure. I}; gr:

I have carefully read the questions in the foregoing appliwfion and have answered them completely, without reservation” any-flu}, and I declare that my answats and all statements made by me herein and In support of Ihis appiiution are true and correct Shoutd I

lumish any false information on or in suppon of this applimtion. I understand that such adion shalt constitute muse for denial, suspension. or revomtion of any license to practice in the state of Florida in the profusion for which I am applying. I have read‘ understand and agree to comply with the s‘atutes and rules appliable to the practice oimy profession in Florida.

I understand that in the event I am required to submit to an evaiuafion by the messiona"s Resource Newark. my appliation documents will be shared with he program and that the program will provide the Board a! Massage Thetapy and the department wiih ma wrmen result» of the evaluation and any recommendations with regard to ficensure and my practice of the pmfasion.

I understand the application fee is namefundable.

ApplinnlSignatule: CU“ H } LLQ/

Date Signed:W

FLORIDA DEPARTMENT OF '\

Charlie Crisl Ana M‘ Viamonlc Ros. MD, MPH Govemor Slalc Surgeon Gcncml

Augusl 6. 2009

Hai Yue Cui 33437 Parsons BM! #3! Flushing, NY 11354

Dear Licensee:

Congratulations! You have completed the application process for licensure as a Massage Therapist in the State 0! Florida. You have been issued license number MA 56763. You will receive your license and wall cenificale in approximately [our to six weeks. This letter serves as your authorization to praclice until you receive your license.

THIS LICENSE WILL EXPIRE ON 08/31/2011. A renewal notice will be mailed to the last address on record approximately ninew (90) days before you: license expires. Address changes mus! be submilted in writing to the Board office as soon as possible in order to ensule all mailings, including renewal inlormation, make it to their proper destinations. It is your responsibility to renew the license whether or not you receive a renewal notice.

You will be required to complete all continuing'educalion requirements outlined in rule 6487-28, F.A.C.. prior to 08/31/2011. For information on continuing educafion requirements. please refer lo our web site an www.doh.stale.1l.uslmqalmassagelma_home.hlmI or contacl lhe Board office a! (850) 488-0595,

IMPORTANT INFORMATION TO NEW LICENSEES In order to keep your license active and free from disciplinary aclion, you must recognize your responsibility to:

1. Post your currenl license at each localion in which you praclice. 2. Verity that each massage establishment in which you praclice has a currenl. active massage

eslablishmen! license. To verify a license, you may visit our website or call Licensure Services an

(850) 488-0595. 3. Keep intermed of the current laws and rules governing the practice of massage Iherapy, Saleguard

your righl to practice.

The Depanmem of Health is committed lo continuous improvement in customer service. As a lecenl licensee, you are one of our most valuable customers and how youJeel about the service we provide you matters a great deal. To make it simple for you to share your opinions, we have developed an on-line survey that takes just a lew momenls to complete. Please complete our customet satislaclion survey at www.doh.stale.fl.us/mga/surveys/new—lic‘hlm. The brief lime you lake Io tell us how we plelormed our jobs will help us belter serve you and the other new licensees in the luture.

If you have any quesiions or concerns. you may contact the Board Office at (850) 488-0595. You may also visit our website at www.doh.slate.tl.us/mqalmassage_home.html tor additional inlormalion concerning your new license Please don'x forget to share your opinion of the service we provide by completing our survey at www.doh.slale.l|.us/mgalsuweys/new-Iichlm. We promise to use the information you provide to improve our service.

Welcome to Florida,

WWW, FILE BQPE Regulatory Specialisl I

Board of Massage Therapy

BOARD OF MASSAGE THERAPY 4052 Bald Cypress Way. Bin COB

Tallahassee, FL 32399-3256 www.doh.stale.fl.uslmqa Fax: (850) 850-921-6184

Charlie Crisl Ann M, Viamomc Ros, M.D.. MPH Govcmor Stale Surgeon Gcncml

May 27, 2009

Hai Yue Cui 33-37 Parsons Blvd #Sf Flushing, NY 11354

Dear Ms. Cui:

The Board of Massage Therapy has received your application for licensure in the State of Florida. Upon initial review, your application has been deemed INCOMPLETE for the following reason(s):

We have not received an official exam score directly from the National Certification Board (NCB). Please contact NCB directly at 800-296-0664 and have them forward your score to our office.

In order to complete the application process, please submit the following information requested above to the address listed below. In order to expedite the processing of your application, please attach all items to a copy of this letter‘ Please be advised that any information received by our office may require additional explanation and/or documents to be reques‘ed in order to further determine your licensure eligibility. As a reminder, please understand that Chapter 456.013(1)(a), Florida Statutes, provides that an incomplete application shall expire one year after initial filing with the department.

If you should have any questions pertaining to this matter, please do not hesitate to contact our office at the address or call me at (850) 245-4444 ext. 3493 or e-mail at jacqueline_c|[email protected]|.us.

Sincerelx,

\ me Clahar

Réé‘gulatory Specialist

CQW

BOARD OF MASSAGE THERAPY 4052 Bald Cypress Way. Bin 006

Tailahassee, FL 32399-3256 hnpzllwww.doh.state.fl.us Fax: (850) 850921-6184


Rick Scott Governor





June 2, 2016 Haiyue Cui 3425 146th St 2nd Fl Flushing, NY 11354


_____We have not received a passing score directly from the National Certification Board of Therapeutic Massage and Bodywork (NCBTMB). Please contact the NCBTMB and have them release your score to our office. They may be reached at 1-800-296-0664 or at www.ncbtmb.org. _____We have not received your Livescan results. If you have already had your electronic fingerprinting (Livescan) completed, please allow 24-72 hours for receipt of your results. The Board of Massage Therapy cannot accept hard copy (paper) fingerprint cards. All applicants must have electronic fingerprinting completed by a Florida Department of Law

Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.flhealthsource.gov/background-screening

Please use the electronic fingerprint form found in the application or on our website at:

http://floridasmassagetherapy.gov/resources/ _____You have indicated that your massage therapy education was completed outside of Florida. Please submit the following: 1. Official transcript mailed directly from your massage therapy school. If the school has closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript. 2. Please have your school complete the Breakdown of Hours worksheet and submit it to our office, outlining the courses that fulfill the requirements for licensure. The form is located in the Forms & Requests section on the following page: http://floridasmassagetherapy.gov/resources/. 3. Please submit proof of your massage therapy school's approval by the equivalent State licensing agency or State Department of Education in which it is located.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure

_ _ Rick Scott Mussmn: To preheat, pramie 8(i health

Gwemor

M'Wemflm‘hmwimegm‘ed ‘ , Celeste Philip MD MPH

stale,oaIny&oannnnyefims. ' ' '

HEALTH SIgeonGena‘el aMSaretay

Vision: Tobe the Healthist State in the Malian

June 2, 2016

Haiyue Cui 3425146th St 2nd Fl

Flushing, NY 11354

File No. 88361

Dear Applicant:


We have not received a passing score directly from the National Certification Board of Therapeutic Massage and Bodywork (NCBTMB). Please contact the NCBTMB and have them release your score to our office. They may be reached at 1-800-296-0664 or at www.ncbtmb.org.

We have not received your Livescan results. If you have already had your electronic fingerprinting (Livescan) completed, please allow 24-72 hours for receipt of your results. The Board of Massage Therapy cannot accept hard copy (paper) fingerprint cards.

> All applicants must have electronic fingerprinting completed by a Florida Department of Law Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.f|healthsource.gov/background- screening

> Please use the electronic fingerprint form found in the application or on our website at: http://f|oridasmassagetherapy.gov/resources/

You have indicated that your massage therapy education was completed outside of Florida. Please submit the following: 1. Official transcript mailed directly from your massage therapy school. If the school has closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript. 2. Please have your school complete the Breakdown of Hours worksheet and submit it to our office, outlining the courses that fulfill the requirements for licensure. The form is located in the Forms & Requests section on the following page: http://f|oridasmassagetherapy.gov/resourcesl. 3. Please submit proof of your massage therapy school's approval by the equivalent State licensing agency or State Department of Education in which it is located.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure

4052 Bad W WWI Bi” 006 ' Td'messee' FL 323993256 Public Health Accreditation Board


P H A B

eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username cuihaiyu and password t9s9eW96 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,

Michaelynn Smith Regulatory Specialist I

eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department.

You may follow the progress of your application through our website at: http://ww2. h. t t .fl. m rvi | in. p Once there, select your profession and enter your usernameWsto check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.

If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at info@floridasmassagetheragygov or at the address below.

Sincerely,

T0 9% @W‘x Michaelynn Smith Regulatory Specialist I

FLORIDA I


HARRY, MARGARET E

DATE OF BIRTH: _ FILE NUMBER: 88090 COMPLETION DATE: 07/22/2016

Criminal History



Rick Scott Governor






August 12, 2016 File:88090

To: Margaret E Harry

5445 Apt D Byrom Street Milton, FL 32570



Rick Scott Mussmn:

Gwemor To protect, [Jamie & imam/e the health 0d peopie in Florida througw inlegaled stale, cany&oomn1ityeffa1$. Celeste Philip, MD, MPH

HEALTH WWMW Vision: Tobe the Healthiest State in the Malian


August 12, 2016 File:88090

To: Margaret E Harry 5445 Apt D

Byrom Street Milton, FL 32570








Sincerely,

J r

,

.,

fLU/ fig _

j ‘





P

of 5Date Created: Apr 28 2016 9:03AM




Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: MARGARET E HARRYDate of Birth: 03/17/1962Place of Birth: EVEREUX, FRANCEEmail Address: [email protected]

Basic Data

Mailing Address5445 APT D BYROM STREET MILTON, FL 32570

Physical Location or Address of Employment5445 APT D BYROM STREET MILTON, FL 32570


Equal Opportunity DataGender: FEMALERace: WHITE

Education History


School Name: LOCKLIN TECHSchool Address:Graduation or Anticipated Graduation Date: 04/27/2016Total Number of Hours Completed: 750


I have a high school diploma and/or GED.

Other Name HistoryName: MARGARET ELIZABETH GRIFFITH

Other State Licenses

License Number: 38724License Type: REGISTERED NURSELicensure Date: 02/04/1987Date of Expiration: 12/31/1998Country: UNITED STATESState: WEST VIRGINIA

License Number:License Type:Licensure Date:Date of Expiration:Country:State:


Mission: To protect, promote, & improve the health 01 all people in Florida through integrated 3‘- state, county & community eflorts. Florld>a


Rick Scott Governor



Mailing Address 5445 APT D

BYROM STREET MILTON, FL 32570




MASSAGE THERAPIST INITIAL MASSAGE THERAPIST EXAM APPLICATION

E HARRY

EVEREUX, FRANCE MEHARRY3@YAHOO .COM

tsical Location or Address of Emplovment 5445 APT D BYROM STREET MILTON, FL 32570



Gender: Race:

Education Histom

850—503—5966

School Name:

School Name: School Address:

Graduation Date: Total Number of Hours Completed:

Graduation or Anticipated

LOCKLIN TECH

04/27/201 6

750

FEMALE WHITE

OTHER FLORIDA BOARD School Name: APPROVED SCHOOL NOT School Name: LISTED School Address:

Graduation or Anticipated Graduation Date: Total Number of Hours Completed:

I have a high school diploma and/or GED.

Other Name Histozy

Name:


MARGARET ELIZABETH GRIFFITH

License Number: License Type: Licensure Date: Date of Expiration: Country: State:

38724 License Number: REGISTERED NURSE License Type: 02/04/1987 Licensure Date: 12/31/1998 Date of Expiration: UNITED STATES Country: WEST VIRGINIA State:



Date Created: Apr 28 2016 9:03AM Page 1 of 5




Provider Number: Provider/School Name: LOCKLIN TECH Course Name/Title: HSCOOO3K Date Completed: 04/27/2016

Prevention of Medical Errors I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B7—25.001(1)(f), F.A.C. Provider Number: Provider/School Name: LOCKLIN TECH Course Name/Title: HSCOOOBK Date Completed: 04/27/2016

HIV/AIDS Course


Provider Number: Provider/School Name: LOCKLIN TECH Course Name/Title: HSC0003K Date Completed: 04/27/2016



Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Your answer: No

Discipline Histom



Have you ever been refused a license to practice massage therapy or any other Your answer: NO

professional license — or renewal thereof— in any state or otherjurisdiction?

Have you ever had a license or certificate of registration to practice massage therapy or Your answer: No any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in


Are you now or have you ever been a defendant in a civil litigation in which the basis of Your answer: NO

the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?

Is there currently pending against you (in any state orjurisdiction) a complaint against Your answer: N0 your professional conduct or competence?

In the last five years, have you been expelled, suspended from, or had disciplinary action Your answer: NO

taken against you by an educational institution other than your high school?

Date Created: Apr 28 2016 9:03AM Page 2 of5
















Email Notification




Rick Scott Governor





May 17, 2016 Margaret E Harry 5445 Apt D Byrom Street Milton, FL 32570


We have not received an official transcript mailed directly from your massage therapy school. If the school has closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript. The background screening results received show “CHARGE” from DATE that was not disclosed on the application. Please provide the below documentation. (1.) A self-explanation describing the details of your criminal history written in your own words. If it is determined that your application must appear before the Board, this is what the Board will read. (2.) Documentation from the Clerk of Court in the county the offense occurred pertaining to the charge. This should include any arrest documentation, disposition of each charge and proof of successful completion of sentencing. We have not received verification of your license(s) directly from the licensing agency. Verification must indicate dates of licensure, method of licensure, and if there has been any discipline/complaints.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your

_ _ Rick Scott Mussmn: To preheat, pramie 8(i health ________

Gwemor

of all We in Flemming“ Megraled ‘ 7 Celeste Philip, MD, MPH

stale, oomty&ommnfly efia‘ts.

H EALTH Interim Stale Slgeon General


May 17, 2016

Margaret E Harry 5445 Apt D Byrom Street Milton, FL 32570

File No. 88090

Dear Applicant:


We have not received an official transcript mailed directly from your massage therapy school. If the school has closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript.

The background screening results received show “CHARGE" from DATE that was not disclosed on the application. Please provide the below documentation.



We have not received verification of your |icense(s) directly from the licensing agency. Verification must indicate dates of licensure, method of licensure, and if there has been any discipline/complaints.


You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/Iogin.asp Once there, select your profession and enter your



P H A B

username harrymar and password Bama1962 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,

Gerry Nielsen Regulatory Specialist II

usernam—to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


Sincerely,

/ R


FLORIDA I


HINKLE, TIMOTHY DATE OF BIRTH: FILE NUMBER: 85911 COMPLETION DATE: 08/12/2016

Criminal History **APPL|CANT DID NOT DISCLOSE THE FOLLOWING CRIMINAL HISTORY ON INITIAL

APPLICATION**



Rick Scott Governor






August 12, 2016 File:85911

To: Mr. Timothy Neil Hinkle

1722 North N St Lake Worth, FL 33460



Rick Scott Mussmn. (Bu/em Toprded, manna/en's health 0d peopie in Florida througw integrated stale, cany&oannnflyeffms. Celeste Philip, MD, MPH

HEALTH WWMWY Vision: Tobe the Healthist State in the Malian


August 12, 2016 File:85911

To: Mr. Timothy Neil Hinkle 1722 North N St Lake Worth, FL 33460








Sincerely,

,/ _

’ L4,]

’ WIZU/y/(VI

'

/ a



4052 Bad W W” Bi" 006 ' Td'messee' FL 323993256 Public Health Accreditation Board


P H A B

of 5Date Created: Sep 29 2015 12:33PM




Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: MR. TIMOTHY NEIL HINKLEDate of Birth: 10/08/1991Place of Birth: COLUMBIA MDEmail Address: [email protected]

Basic Data

Modifier: Military Veteran Fee Waiver - I have been honorably discharged from a branch of the United States Armed Forces within the previous 60 months.

Mailing Address1722 NORTH N ST LAKE WORTH, FL 33460

Physical Location or Address of Employment1722 NORTH N ST LAKE WORTH, FL 33460

Phone NumbersHome: 631-513-6432Business: 561-703-5708

Equal Opportunity DataGender: MALERace: WHITE

Education History

School Name: ACADEMY OF PALM BEACH








Date Completed: 04/24/2015Course Name/Title: 20-152859

Provider Number: MCE7-20Provider/School Name: ACADEMY OF PALM BEACH

Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. firidz

HEAL'I H Vision: To be the Healthiest State in the Nation

Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary


Modifier:

Mailing Address 1722 NORTH N ST LAKE WORTH, FL 33460




MASSAGE THERAPIST INITIAL MASSAGE THERAPIST EXAM APPLICATION MR. TIMOTHY NEIL HINKLE— COLUMBIA MD T|MOTHYNE|LH|NKLE@GMA|L.COM

Military Veteran Fee Waiver — I have been honorably discharged from a branch of the United

States Armed Forces within the previous 60 months.

tsical Location or Address of Emplovment 1722 NORTH N ST LAKE WORTH, FL 33460



631 —51 3—6432

561 —703—5708

Gender: MALE Race: WHITE

Education Histom

School Name: ACADEMY OF PALM School Name: BEACH School Name:

School Address: School Address: Graduation or Anticipated Graduation or Anticipated Graduation Date: 09/27/2015 Graduation Date: Total Number of Hours Total Number of Hours Completed: 624 Completed:

Other Name Histozy








Provider Number: Provider/School Name: Course Name/Title: Date Completed:

MCE7—20 ACADEMY OF PALM BEACH 20—152859 04/24/2015

Date Created: Sep 29 2015 12:33PM Page 1 of 5

Prevention of Medical Errors I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B?—25.001(1)(f), F.A.C. Provider Number: MCE7—20 Provider/School Name: ACADEMY OF PALM BEACH Course Name/Title: 20452862 Date Completed: 07/13/2015

HIV/AIDS Course


Provider Number: MCE7—20 Provider/School Name: ACADEMY OF PALM BEACH Course Name/Title: 20—10856 Date Completed: 04/26/2015


Acknowledgement Statement I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy, and right to challenge incorrect criminal history records and the "Privacy Statement" document from the Federal Bureau of Investigation.

Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense?

Discipline Histom

Have you ever been denied the right to take a massage therapy (or any other medical or personal service) licensing examination in any state orjurisdiction?

Have you ever been refused a license to practice massage therapy or any other professional license — or renewal thereof— in any state or otherjurisdiction?

Have you ever had a license or certificate of registration to practice massage therapy or any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in


Are you now or have you ever been a defendant in a civil litigation in which the basis of the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?

Is there currently pending against you (in any state orjurisdiction) a complaint against your professional conduct or competence?

In the last five years, have you been expelled, suspended from, or had disciplinary action taken against you by an educational institution other than your high school?

Date Created: Sep 29 2015 12:33PM

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Page 2 of 5

















Military Veteran Fee Waiver Date of Discharge: Your answer: 03/14/2012

Email Notification



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File No. 35911

Dear Applicant

Thus lener IS m reference to your apphcauon for massage (herapusl hcensure Upon mmal revlew‘ your applicauon has been deemed g the lollowmg veasDn(S)

The background screening resulls received show "CHARGE" lrom DATE max was n01 dusdosed on the application Please pro

documentation

(1 )A Sell-explanahon descnbmg me delalts of your crimma! history written in your own words u a: \s determvned that your appl

appear before the Beard [ms 5 what the Board wwl! read,

(2 1 Documentation from me Clerk of Court in the coumy the oflense occurred pertaining to the charge This should 'mclude an-

documentation. disposition 0! each charge and prool of successful comp|euun of sentencing

We have not renewed an offic‘al transcript containing me school seal, on counkerfen-proof paper. mailed mrectly Irorn a massa

School, The school must be approved by the equivalent Stale licensmg agency or State Department of Educatian in which it is

lncbude ihe above file number on all conespondence to our office Please be advised any inlormation received by our office may reql

explanation and/or documents to determine your "censure ehgibility, As a remmder. Secuon 456.013(1)(a) Fionda Stmutes. s1ates an

application shall expxre one year after initial filing with the depanmenlv

http /m7ail.google.com/mail/u/0/ 10/12/2015


Rick Scott Governor








November 3, 2015 Mr. Timothy Neil Hinkle 1722 North N St Lake Worth, FL 33460


The background screening results received show “CHARGE” from DATE that was not disclosed on the application. Please provide the below documentation. (1.) A self-explanation describing the details of your criminal history written in your own words. If it is determined that your application must appear before the Board, this is what the Board will read. (2.) Documentation from the Clerk of Court in the county the offense occurred pertaining to the charge. This should include any arrest documentation, disposition of each charge and proof of successful completion of sentencing.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username timhinkle and password Timothy1 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Rick Scott Mussmn:





November 3, 2015

Mr. Timothy Neil Hinkle 1722 North N St Lake Worth, FL 33460

File No. 85911

Dear Applicant:






You may follow the progress of your application through our website at: http://

' ' ce there, select your profession and enter your

userna eck your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.



P1NTEREST: Han/Fla

Sincerely,


Sincerely,



Rick Scott Governor





June 3, 2016 Mr. Timothy Neil Hinkle 1722 North N St Lake Worth, FL 33460


We have received your documentation concerning “WRONGFUL USE OR POSSESSION” (US ARMY, QUANTICO), but the background screening results show the following additional information: The subject may have additional criminal justice information as noted below: Information Type: Probation OR Supervised Release Status Contact Agency: MD014105G Telephone Numbers: MD DIV PAROLE PROBATION ELLICOTT CITY OFFICE 410 480-7920

o For more information, please call the above listed agency directly. o And, please provide the contact agency with PCN Number and/or NIC Number C383371861 which will assist their staff in locating the specific record information that maybe associated with your subject.

This coincides with the following charge: DWU -- ALCOHOL (06/04/2015) -- from the same agency. Please provide additional documentation for the above.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username timhinkle and password Timothy1 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

. . Rick Scott Mussmn:

3 mar To noted, pmme & inm/e the health

of all peopie in Flam mrmgw integrated stale, cany&ommnflyefims_ Celeste Philip, MD, MPH

HEALTH WWMSW Vision: Tobe the Healthiest State in the [Him

June 3, 2016

Mr. Timothy Neil Hinkle 1722 North N St Lake Worth, FL 33460

File No. 85911

Dear Applicant:



You may follow the progress of your application through our website at: http://ww2

' '

p Once there, select your profession and enter your username to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


4052 Edda/9mm“ Binom' ”lemma RW3256 H A B Public Health Accreditation Board

Florida Department of Health DV'S'mOf WM WWWW 31'9”d m Accredited Health Department PHONE (850)2454444 - FAX: (850)4122681

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FLORIDA I


MACKERT, DAVID ANTHONY DATE OF BIRTH: — FILE NUMBER: 86353 COMPLETION DATE: 03/18/2016



Rick Scott Governor






August 12, 2016 File:86353

To: David Anthony Mackert

912 Raven Ave Miami Springs, FL 33166



Rick Scott Mussmn:




August 12, 2016 File:86353

To: David Anthony Mackert 912 Raven Ave Miami Springs, FL 33166








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4052 WWW” Binme' Td'messee' FLm3256 H A B Public Health Accreditation Board


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Do Not Write in this Space massage Therapist For Revenue Receipling Only

wg Licensure Application 11/ 10/2015 155 . 00 a Fl

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HEALTH Web: mfiorigasmg§§ggethgra9L99v R3: 915024344

Email: mmmw Fees must be paid in the form of a cashiers check or money order, made payable to: Department of Health

Choose your application type: The tota| fee of$155.00 includes the following:

Massage Therapist by Examination (x-1021) [35155.00 Initial Ligensure Fee $100.00

Massage Therapist by Endorsement (x—1022) D$155.00 Applicatlon Fee $5000 Unlicensed Ac1ivity Fee $5.00

An applicant. who is denied licensure, or withdraws the application prior to licensure, is entitled to a refund of $105.00 (initial Iicensure fee and unlicensed activity fee). A request to withdraw and/or receive a refund must be made in writing. Fees are refundable for up to 3 years from the date of receipt.

1. PERSONAL INFORMATION

Name: Macken David Anthony Date of BMW Last/Sumame Fll’St Mlddle

Mailing Address: (The address where mail and your license should be sent.) _ _ _

912 Raven Ave Mlam' Springs Street] PO Box $uute77§pt No City

FL 33166 USA 786-316-2239 State Zip Country ome e um r

Physical Location: (Required if mailing address is a PO Box. This will be posted on the Department’s website.)

Street/ PO Box Suite/Apt. No City

State Zip COUHW Work/ Cell Number

Equal Opportunity Data: We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 CFR38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.

SEX: Male [3 Female RACE-White I] Black DAsiaaacific Islander |:|Hispanic Domer

Email Notification: If you want to be notified of the status of your application by email. please check the "Yes“ box and write your email address on the line provided below. If you choose this form of notification. you will receive information regarding your application file through email. You will be responsible for checking your email regularly and updating your email address with the Board office at: |nfgglggigasmassagethera21.9gv

I want to be notified by email: .Yes EINo Email Address: [email protected]

Under Florida law, email addresses are public records. If you do not want your e—mail address released in response to a pubiic records request. do not provide an email address or send elecmmic mail to our office. Instead contact the oflioe by phone or in writing.

Rule 6487-25001, FAG. .

Page 1 of 13 DH—MQA 1115, 6/14

NAME Mackert5 Dam A 2. MASSAGE THERAPY EDUCATION HISTORY

A. Massage Therapy School Graduated From: Awnuncture and Massage College

10506 N Kendall Dr Miami FL USA Street City State Country

B. Date Graduated] Anticipated Graduation (mm/dd/yyyy) : 04/28/2014

C. Additional Massage Therapy School Attended:

Street CRY State Country D. Date Graduated] Anticipated Graduation (mm/dd/yyyy) :

E. I authorize the school(s) listed above to release my official transcdpt(s) directly to the Florida Board of Massage Therapy. Yes [:1 No

3. APPLICANT BACKGROUND

A. List any other name(s) by which you have been known in the past.

B. List all health related licenses you have ever held (active. inactive or lapsed). State/County Profession License No. Date Of Licensure

4. MANDATORY FLORIDA EDUCA'I10N REQUIREMENT

Completion of a two (2) hour course on Prevention of Medical Errors. a ten (10) hour course on Florida Laws and Rules and a three (3) hour course on HIV/AIDS is required prior to licensure. These courses must be from a Florida Board of Massage Therapy approved CE provider or massage school.

| attest l have completed the required courses listed above. IZIYes DNO If you checked "No", you must submit your course completion certificates to the Board office.

5. DISCIPLINARY HISTORY

If you answer “Yes" to any of the questions in this section, you are required to send the following items:

0 Self Explanation, describing in detail the circumstances surrounding the disciplinary action. 0 A copy of the Administrative Complaint and Final Order. 0 Three (3) current (written within the last year) professional Letters of Recommendation.

A. [:]Yes M No Have you ever been denied or is there now any proceeding to deny your application for any healthcare license to practice in Florida or any other state. jurisdiction or country?

C. es I/ No Have you ever had disciplinary action taken against your license to practice any healthcare related profession by the licensing authority in Florida or in any other state. jurisdiction or country?

B. Yes V No Have you ever surrendered a license to practice any healthcare related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?

D. Yes M No Do you have any disciplinary action pending against your license?

Failure to disclose information in the above section may result in a denial of your application. Rule 6437-25001, F.A.C. Page 2 of 13 DH-MQA1115, 6/14

NAME Mackert \ D “V\ a 6. CRIMINAL HISTORY Answers to commonly asked questions can be found on our website at:

hflgzllwwlon'dasmassagetharaexgovlhelg-conterlilfags

If you answer "Yes” to any of the questions in this section, you are required to send the fo||owing items:

0 Self Explanation describing in detail the circumstances surrounding each offense; including dates, city and state. charges and final results.

0 Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the Clerk of the Court.

0 Completion of Sentence Documents. You may obtain document from the Department of Corrections. The report must include the start date, end date and that the conditions were met.

0 Three (3) current (written within the last year) professional Letters of Recommendation.

A. V Yesl [No Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a cn'me in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld.

Reckless driving, driving while license suspended or revoked (DWLSR), driving under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses for purposes of this question.

B. Yes 3’ INo Have charges ever been brought against you by any branch of the United States Armed Services?

Failure to disclose information in this section may result In a denial of your application.

7. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS

Applicants for Iicensure, certification or registration and candidates for examination may be excluded from lioensure, certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. If you answer “Yes" to any of the following questions, please provide a written explanation for each question including the county and state of each termination or conviction. date of each termination or conviction, and copies of supporting documentation to the board office. Supporting documentation includes court dispositions or agency orders where applicable.

1.[ Yes I/ No Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a fe|ony under Chapter 409. F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar fe|ony offense(s) in another state or jurisdiction?

If you responded “No" to the question above, skip to question 2.

a. DYGSD No If “Yes" to 1, have you successfully completed a drug court program for a felony offense that resulted in the plea being withdrawn or charges dismissed?

b. DYesEl No If “Yes” to 1, for felonies of the first or second degree, has it been more than 15 years before the date of application?

am Yes DNo If “Yes" to 1, for felonies of the third degree, has it been more than 10 years before the date of application, except for felonies of the third degree under Section 893.13(6), Florida Statutes?

d. [:|Yes DNo If “Yes” to 1. for felonies of the third degree under Section 893.13(6)(a), Florida Statutes, has it been more than 5 years before the date of application?

Rule 6437-25001. F.A.C. DH-MQA 1115, 6/14 Page30f13

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2. D Yes I: No Have you been convicted of. or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 use 55. 801-970 (relating to controlled substances) or 42 U.S.C. ss. 13954396 (relating to public health, welfare, Medicare and Medicaid issues)?


a. D Yes El No If “Yes" to 2, has it been more than 15 years before the date of application since the sentence and any subsequent period of probation for such conviction or plea ended?

3- [I Yes [El No Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes?


a. I] Yes 1] No If you have been terminated but reinstated, have you been in good standing with the Florida Medicaid Program for the most recent five years?

4. [:1 Yes IE No Have you ever been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid Program?

If you responded “No” to the question above, skip to question 5.

a. E] Yes [jNo Have you been in good standing with a state Medicaid program for the most recent five years?

b- D Yes DNo Did the termination occur at least 20 years before the date of this application?

5. [I Yes El No Are you currenfly listed on the United States Department of Health and Human Services Office of Inspector General‘s List of Exduded Individuals and Entities?

6. D Yes a No If “Yes" to any of the questions 1 through 5 above, on or before July 1, 2009, were you enrolled in an educational or training program in the profession in which you are seeking licensure that was recognized by the Board of Massage Therapy or Department of Health?

8. EXAMINATION HISTORY

Please indicate which of the following licensure examinations you have passed.

Name of Examination State/County Month/Year

E] NCBTMB

El NCETM

El NESL _ MBLEX FUUSA _

D Other:

9. AVAILABIIJTY FOR DISASTER

IE] Yes El No Will you be available to provide health care services in special needs shelters or to help staff disaster medical assistance teams during times of emergency or major disaster?

Rule 6437-25001, FAQ Page 4 of 13 DH-MQA 1115, 6/14

David Anthony Mackert NAME

11. LIVESCAN PRIVACY STATEMENT:

I have been provided and read the statement from the Florida Department of Law Enforcement regarding the

y shan’ng, retention, privacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the Federal Bureau of Investigation. (Found in the forms following this application). The Board will not receive your Livescan results if you do not affirm the above statement by checking this box.

12. ELECTRONIC FINGERPRINTING:

All applicants. including out-of-state and out-of-country applicants. are required to submit their fingerprints electronically. The Department of Health accepts electronic fingerprinting offered by Livescan device providers that are approved by the Florida Department of Law Enforcement. For a list of approved Livescan vendots and frequently asked questions, please visit our website at ' . . . . .

Typically background results submitted by Livescan are received by the Board within 24-72 hours of being processed. The Originating Agency Identification (ORI) number for the Board of Massage Therapy is EDOH46002. The Board cannot accept hard fingerprint cards or results. All results must be submitted electronically by the Livescan service provider.

Livescan screenings done by a Florida Police or Sheriff's Department require that you login to the FDLE Civil Applicant Payment System (CAPS) at W and pay a fee before results will be released to our office.

Applicants who reside in an area where no Livescan service providers are available or because of s‘ate laws prohibiting transmission of fingerprints electronically across state lines should contact a Florida Livescan service provider who has the capability to convert a traditional card (hard card) into an electronic fingerprint card.

Because the Florida Department of Health retains fingerprints on any applicant who is required to undergo a criminal history screening as of January 1, 2013, those prints are retained in the Care Provider Clearinghouse. This Clearinghouse allows for the sharing of criminal history information among specified agencies.

One of the requirements for your Livescan to be retained in the Clearinghouse is a photograph taken by the Livescan service provider at time of fingerprinting. If your Livescan is completed without a photograph, you may have to undergo additional fingerprinting in the future.

13. APPLICANT STATEMENT

I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has been submitted if and when any material change in circumstances or conditions occur which might affec‘ the Board’s decision concerning my e|igibility for examination or licensure. Such supplement is required by section 456.0130), F.S. Failure to do so may result in disciplinary action by the Board including denial of Iicensure.

I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare that my answers and all statements made by me herein and in support of this application are true and correct. Should I furnish any false information on or in support of this application, I understand that such action shall constitute cause for denial, suspension, or revocation of any license to practice in the state of Florida in the profession for which I am applying. I hereby acknowledge that pracfice as a licensed Massage Therapist in Florida is governed by Chapters 456 and 480, F.S., and Rule Tifle 6437, F.A.C. I understand that I am under a continuing obligation to understand and keep informed of any changes to Chapters 456 and 480, F.S., and Rule Title 6487. F.A.C.

Applicant Signature: _A%Q H I 1 5 1 Date: '1 g; s )5

This field cannot typ 5d. You mus print the application and sign it. MMIDD

All applications filed with the department are valid for one (1) year from the date of receipt.

Rule 6437—25001. F.A.C. DH-MQA 1115, 6/14 Page 60f 13

FLORIDA BOARD OF MASSAGE THERAPY LICENSE VERIFICATION REQUEST

After completion of this form, please forward this form to the licensing agency of each state by which you are now or have been licensed.

Applicant Name: SSN:

Address:

Name original license was issued under:

License Number: State:

I hereby authorize release of any information regarding my Iicensure status to the Florida Board of Massage Therapy.

Applicant Signature: Date:

STATE LICENSING AGENCY

All verifications shall be completed in English and mailed or sent electronically directly from the state(s) or jurisdiction(s) and must include the following criteria:

a Typed on an official state form or letterhead 1: Include an official Board seal :1 Signature and title of state Board official

The following information must be included in all verifications: u Licensee name

License number State orjurisdicfion of lioensure Dates of issuance/expiration Licensure method; exam type or endorsement Licensure status Is license in good standing? Has this license ever been encumbered (denied, revoked, suspended surrendered, limited, placed on probation)?

CIDDDDGD

Complete verifications must be mailed or sent electronically directly from ihe state licensure Board to:

Florida Board of Massage Therapy 4052 Bald Cypress Way Bin c-os Tallahassee, FL 32399-3256

Fax (850) 412-2681 info orida m a thera .ov

Rule 6487-25001, F.A.C. DH-MQA 1115, 6/14 Page 7of13

Florida Board of Massage Therapy Transcript Request Form

If you graduated from a massage therapy program approved by a state other than Florida complete the top section and send this form to your Massage Therapy school to complete and attach your transcripts.

NAME

ADDRESS

SOCIAL SECURITY # DATE OF BIRTH

I authorize the school to release the information requested below to the Florida Board of Massage Therapy.

Signature of Student: Date: MM/DD/YYYY

This section is to be completed by the Dean, Registrar, or Chairperson of the massage therapy program at the United States school from which the applicant graduated.

DO NOT complete this form in anticipation of program completion.

I hereby certify that successfully completed a Massage Name of Applicant

Therapy education program at on School Name MMIDDIYYYY

Street Address State Zip Code

The curriculum completed by Applicant equals or exceeds the curriculum requirements set forth in Rule 64B7-32.003[1 ), F.A.C. (Attached) Hours completed:

The school must be approved by a governmental agency authorized to approve massage therapy programs.

Name of approving agency License/certificate number

Printed name of Dean/RegistrarlChairperson of MT. Program Date

Signature

RETURN THE ORIGINAL COMPLETED FORM. OFFICIAL STUDENT TRANSCRIPTS, AND PROOF OF SCHOOL APPROVAL DIRECTLY TO THE BOARD OFFICE.

Please mail to: Florida Board of Massage Therapy, 4052 Bald Cypress Way, Bin 006, Tallahassee. FL 32399-3256

Rule 6487-25001, F.A.C. DH-MQA1115.6/14 Page90f13

6437-31003 F.A.C. Minimum Requirements for Board Approved Massage Schools.

(1) In order to receive and maintain Board of Massage Therapy approval, a massage school, and any satellite location of a previously approved school. must:

(a) Meet the requirements of and be licensed by the Department of Education pursuant to Chapter 1005. F.S., or the equivalent licensing authority of another state or county, or be within the public school system of the State of Florida; and

(b) Offer a course of study that includes, at a minimum, the 500 classroom hours listed below, completed at the rate of no more than 6 classroom hours per day and no more than 30 classroom hours per calendar week:

Course of Study Classroom Hours Anatomy and Physiology 150 Basic Massage Theory and History 100 Clinical Practicum 125 Allied Modalities 76 Business 15 Theory and Practice of Hydrotherapy 15 Florida Laws and Rules 10 (Chapters 456 and 480, F.S. and Chapter 6437, F.A.C.) Professional Ethics 4 HIV/AIDS Education 3 Medical Errors 2

Rule 6487-25001. F.A.C. DH-MQA1115,6/14 "

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MARUCA, JOE DATE OF BIRTH: _ FILE NUMBER: 89130 COMPLETION DATE: 07/27/2016

Disciplinary History

Previous License: MA2884 Case Number: 97-14067 Date of Final Order: 02/09/1999 Status: SETTLEMENT AGREEMENT APPROVED;

Administrative fine ($250.00) paid within 30 days Reprimand Complete deficit CE hours (HIV/AIDS)

Current Status: NULL AND VOID



Rick Scott Governor






August 12, 2016 File:89130

To: Mr. Joe Maruca

4340 Nw 46th Terrace Gainesville, FL 32606



Rick Scott Mussmn:




August 12, 2016 File:89130

To: Mr. Joe Maruca 4340 Nw 46th Terrace Gainesville, FL 32606








Sincerely,

b J

Y

I, V,

/ L17 / JANA

>



4°52 BeldO/pmsWay, Binme' Td'messeev FLm3256 H A B Public Health Accreditation Board


P

Rick Scott

Celeste Philip, MD, MPH SurgeonGeneral and Secretary

Governor


Mission:To protect, promote & improve the healthof all people in Florida through integratedstate, county & community efforts.

Vision:To be the Healthiest State in the Nation

Application Summary

Application DetailLicense Type: Massage Therapist

Profession Number: 1401 - Massage Therapist

File Number: 89130

Application: Massage Therapist by Examination

Application Date: 07/27/2016

Application QuestionsMilitary Veteran Fee Waiver - I have beenhonorably discharged from a branch of theUnited States Armed Forces within theprevious 60 months.

No

Military Veteran Spouse Fee Waiver - I amthe spouse of a military veteran who hasbeen honorably discharged from a branch ofthe United States Armed Forces within theprevious 60 months.

No

Personal DetailTitle: Mr.

First Name: Joe

Last Name/Surname: Maruca

Birthdate: 01/08/1950

Gender: Male

Race: White

Social Security Number: *****4986

Addresses Main Address Address: 4340 NW 46th 4340 NW 46th Terrace

FL

Gainesville, FL

32606

US

Page 1 of 67/27/16 5:28 PM


HEALTH

Rick Scott Governor




Application Summary

Application Detail License Type:

Profession Number:

File Number:

Application:

Application Date:

Application Questions Military Veteran Fee Waiver - I have been honorably discharged from a branch of the United States Armed Forces within the previous 60 months.

Military Veteran Spouse Fee Waiver - I am the spouse of a military veteran who has been honorably discharged from a branch of the United States Armed Forces within the previous 60 months.

Personal Detail Title:

First Name:

Last Name/Surname:

Binhdate:

Gender:

Race:

Social Security Number:

Addresses Main Address

Address:

7/27/16 5:28 PM

Massage Therapist

1401 - Massage Therapist

89130

Massage Therapist by Examination

07/27/2016

No

No

Mr.

Joe

Maruca

Male

White

4340 NW 46th 4340 NW 46th Terrace

FL

Gainesville, FL

32606

US

Page 1 of 6

Phone Number: 352-336-1661

Extension: 1661

E-mail Address: [email protected]

Physical Location Address: 4340 NW 46th 4340 NW 46th Terrace

FL

Gainesville, FL

32606

US

Phone Number: 352-336-1661

Extension: 1661

Education History Massage School: OTHER FLORIDA BOARD APPROVED

SCHOOL NOT LISTED

Date of Graduation or Anticipated 08/05/1975 Graduation (mm/dd/yyyy):

Total Number of Hours Completed (Please 1000 use numbers only with no decimals (example 200):

I authorize the school(s) listed above to release my official Yes transcript(s) directly to the Florida Board of Massage Therapy.

Exam History Examination:

State:

Country:

Date of Exam:

Other:

Other State Licenses Do you now hold or have you ever held a license to practice Yes Massage Therapy or any other profession in any US State or territory, or foreign country?

License Number: MA2884

Type: Massage Therapy

Original Date Issued: 09/30/1975

Date of Expiration: 08/31/2013

Country: UNITED STATES

7/27/16 5:28 PM Page 2 of 6

State: Florida

Have you completed a three hour course on HIV/AIDS as Yes required by Florida Statute?

Provider Number: 733

Provider/School Name: One Stop Continuing Education, LLC

Course Number/Title: HIV

Date Completed: 06/22/2015

Ten Hour Florida Laws and Rules Course As a condition of licensure, you must complete a ten hour Florida laws and rules course administered by a Florida Board approved school or a Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. I have completed a ten hour Florida laws and rules course as Yes defined in rule 64B7-32.003, F.A.C.

If you have completed this requirement as part of your curriculum, please list your school in the "Provider/School Name" field and your graduation date in the "Date Completed" field below. Likewise, if you completed this requirement as an apprentice, list the name of your sponsor in the "Provider/School Name" field and your apprentice completion date in the "Date Completed" field. Provider Number: 733

7/27/16 5:28 PM Page 3 of 6

Provider/School Name: One Stop Continuing Education, LLC

Course Number/Title: Medical Errors, Laws, Ethics, Hand Therapy Course


Criminal History Have you EVER been convicted of, or entered a plea of guilty, No nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld.

Reckless driving, driving while license suspended or revoked (DWLSR), driving under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses for purposes of this question. Discipline History - Denial Have you ever been denied or is there now any proceeding to No deny your application for any healthcare license to practice in Florida or any other state, jurisdiction or country?

Discipline History - Surrender Have you ever surrendered a license to practice any No healthcare related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?

Discipline History - Disciplined Have you ever had disciplinary action taken against your Yes license to practice any healthcare related profession by the licensing authority in Florida or in any other state, jurisdiction or country?

Name of Agency: Florida DoH

Date of Action: 02/26/1999

Final Action: FINE

Applicant Statement: Got a fine for misplacing my answer sheet and it never got mailed.

Discipline History - Pending Do you have disciplinary action currently pending against any No license?

Medicaid/Medicare (Applicants) 1. Have you been convicted of, or entered a plea of guilty or No nolo contendere to, regardless of adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction?

7/27/16 5:28 PM Page 4 of 6

2. Have you been convicted of, or entered a plea of guilty or No nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. 55. 801-970 (relating to controlled substances) or 42 U.S.C. 55. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)?

3. Have you ever been terminated for cause from the Florida No Medicaid Program pursuant to Section 409.913, Florida Statutes?

4. Have you ever been terminated for cause, pursuant to the No appeals procedures established by the state, from any other state Medicaid program?

5. Are you currently listed on the United States Department No of Health and Human Services Office of Inspector General‘s List of Excluded Individuals and Entities?

Electronic Fingerprinting I have been provided and read the statement Yes from the Florida Department of Law Enforcement regarding the sharing, retention, privacy and right to challenge incorrect criminal history records and the 'Privacy Statement‘ document from the Federal Bureau of Investigation.

Enter in today's date 07/27/2016

Availability for Disaster Are you willing to provide health care services in special need No shelters or to work with disaster medical teams during times of emergency or major disasters?

If you respond 'Yes', your name will be added to a data listing that is available to the Department of Health if a disaster is declared. If you live in an area where you may be able to help you will be called on if needed. Fees Application Fee $50.00

Initial License Fee $100.00

Unlicensed Activity $5.00

Total Amount Due: $155.00

Attestation

7/27/16 5:28 PM Page 5 of 6

I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has been submitted if and when any material change in circumstances or conditions occur which might affect the Boardés decision concerning my eligibility for examination or licensure. Such supplement is required by Section 456.013(1), F.S. Failure to do so may result in disciplinary action by the Board including denial of licensure.

I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare that my answers and all statements made by me herein and in support of this application are true and correct. Should I furnish any false information on or in support of this application, I understand that such action shall constitute cause for denial, suspension, or revocation of any license to practice in the state of Florida in the profession for which I am applying. I hereby acknowledge that practice as a licensed Massage Therapist in Florida is governed by Chapters 456 and 480, Florida Statutes, and Rule Chapter 6487, Florida Administrative Code. I understand that I am under a continuing obligation to understand and keep informed of any changes to Chapters 456 and 480, F.S., and Rule Chapter 6487, Florida Administrative Code.

7/27/16 5:28 PM Page 6 of 6

STATE OF FLORIDA BOARD OF MASS! h _' '_'" ‘ _"

FInaIOrdcrNo. DOI‘I-99-00169Dah: .33: - ' -'

FILED DEPARTMENT OF HEALTH, .mmI’Bp‘fl‘éfééig’] 31m

filth. ' -"' .chf- _,. Petitioner, WEI—”Jim“ H h V I

" D:puly Agency Eli-rk

V5. CASE NO: 97-14057 LICENSE NO‘: MA 0002884

JOSEPH P. MARUCA,

Respondent.

f

FINAL ORDER APPROVING SETTLEMENT STIPULATION

THIS MATTER came before the Board of MaSSage Tharapyr a1 a duly-noticed

public meeting held on January 28, 1999, in Ft. Myers, FIorida, pursuant to Seation

120.57(4), Fiorida Statutes, for consideration of the Administrative Complaint

{attached hereto as Exhibit A} and the proposed Stipulation [attached hereto as

Exhibit B} entered into between the parties in the above styled case.

Upon consideration of the Administrative Complaint and the proposed

Settlement Stipuiation in this matter. and being otherwise fully advised in the

premises, it is hertz-tn,r ORDERED AND ADJUDGED:

1, The proposed Stipuiation is hereby approved. adopted, and incorporated

herein by reference.

2. Respondent wiH adhere to and abide by all of the terms and conditions of

the Stipulation.

3. This Order shall be placed in and become a part of Reapondent's officiai

records and shail become effective upon filing with the Clerk of the Department of Health. /?

DONE AND ORDERED this _/day of Iéf/iflgjgzég , 1999.


féyw/oz E. TRIMBLE CHAIR

1'

IF RVI

I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order

has been furnished by U. S. Mail to JOSEPH P. MARUCA, 4340 NW 46th Terrace.

Gainesville FL 32506, and by inter—office mail to Susan Bodell, Senior Attorney,

Agency for Health Care Administration, 2727 Mahan Drive. Talfahassee FL 32308—

5403r this _day of , 1999.

F:\USE FIE LA D M | N\LEE\BOMT\I 439 MTG“.M AFIU CALI H D



PE'ITHONER,

v5. CASE NUMBER: 9?—14067

JOSEPH P. MARUCA

RESPONDENT.f

STIPLEATION

JOSEPH P. MARUCA, hereinafter referred to as Respondent, and the Dcpartmeni of

Health, hereinafter referred to as Depanment, hereby stipulate and agree to Lhe following joint

Stipuiation and Final Order of lhe Board of Massage Therapy, hereinafter referral to as Board.

incorporaijng this Stipulation and agreement in the above-styled matter.

STIPULATED FACTS

1. For all times pertinent hereto, Respondent was a licensed massage therapist in tin: State

of Florida, having baen issued license number MA 002884. Respondent's East known address is

4340 Nonlm-esl. 46‘“ Terrace, Gainesviile, Florida 32606.

2. The Respondent was charged by an Administrative Complaint filed by the Department

and preperly served upon Rcsmndent with violations of Chapter 480, Florida Statutes, and Chapter

455, Florida Statutes. A true and correct copy of the Administrative Complaint is attached hereto

and incorporated by reference as Exhibit A.

1 000834

3. Respondent admits Lhe allagations of fact contained in Lhe Administraiive Complaint for

purposes of these proceedings only.

STIPULATED QQNQLUSIONS OF LAW

1. Respondent, in hisihcr capacity as a licensed massage therapist, admits that in such

capacity hefshe is subject to the provisions of Chapters 455 and 480, Florida Statutes, and the

jurisdictior: of the Agency and the Board.

2. Remndent admits that the facts set forth in tha Administrative Complaint, if pmvcn,

constitute violations of Chapters 455 and 480, Florida Statutes, as alleged in the Administrative

Complaint.

3. Respondent admits lhat LhE: Stipulated Disposiu'on in this case is fair, appropriate and

acceptable to Respondent.

ST‘IPULATED DISPOSITION OF LA“?

1. Respondent shall, in 1.116 future, comply with Chapters 455 and 480. Florida Statutes,

and Lhe rules promulgated pursuant Ihereto.

2. Respondent, to avoid the necessity of furthtr adminieaLivc proceedings in Lhis case,

sLipulatcs to the fOUOwing:

a) The Board shall impose an Administrative fine of two hundred fifty dollars {$250.00)

against the Respondent. Said cost shall be paid by the Respondent to th: Executive Director of the

Board of Massagt Therapy, 1940 Norm Monroe Street, Tallahassoe, Flon'da 32399-9750, witmn

miny (30) days of rendition of the Final Order by Lhe Board of Massage Therapy, which Final

Order incorporates Lhis Stipulation.

2 000635

{b} Respondent‘s 1503115.: to practice massage mempy shall receive a reprimand in this

matter.

(:1) Within six (6) months of rendition of the Fir-31 Order, Respondent shall complete

Lhe deficit hours of continuing educaLic-n in required for the 1995-97 license renewal biennium.

These continuing education hours are in addition to those continuing education hours required for

license renewal. Moreover, those confinuing education hours must be. completed through personal

attendance seminars and not video andfor correspondence cofirscs. Upon completion of said

continuing education hours, the Respondent shall request Lhc provider to submiL verification of

completeness to the Board of Massage Therapy.

((1) Respondent shall appear before the Board at which meeting this stipulation is

presentad.

3. It is expressly understood that this Stipulation is Subject to approval of the Board and

Department and has no force and effect unlil an Order is based upon it by the Board.

4. This StipulatiOH is executed by the Respondent for the purpose of avoiding further

administrafive action by the Board of Massage Therapy regarding Lhc acts or omissions specifically

set forth in the Administrative Complaint, attached as exhibit A. In this regard. ReSpondenl

auflmrizes Lhe Board to review and examine all investigative file. materials concealing Respondent

prior to, or in conjunction wiLh, consideration of Lhe Stipulation. Reapondenl shall offer no

evidence, testimony or argument Lhat disputes or contravenes any stipulated fact or conclusion of

law. Furthermore, should this joint Sfipulafion not be acoepwd by the Board, it is agreed that

3 000636

presentation to and by Lhe Board shall not unfairly or illegally prejudice 1113 Board or any of its

members from further participation, considamfiou or resolution of these procwdings.

5. The Respondent and the Department fully understand that thjsjoint settlement stipulation

and subsequent Final Order incorporating same will not preclude addiLional proceedings by the.

Department :mdfor Board against the Respondent for acts or omissions which are not the subject of

the Administmtive Complaint, attached 35 exhibit A. This stipulatinn relates solely to the current

disciplinaw proceedings arising from the above-mentioned AdminieaLive Complaint and does not

preclude furlhcr acLion by Omar divisions, departments, andfor sections of The Department,

including but not limited to the Department's Medicaid Program Integrity office. If the Stipulation

is relented by the Board of Massage: Therapy, L11: Respondent has not “:51d his rights to a

hean'ng pursuant to Chapter 120, Florida Statutes.

6. Respondent sxpressiy waives all furlhcr procedural steps, and expressly waives all rights

to seek judicial review of or oilmrwise challenge or contest the validity of the joint Sfipulalfion of

facts, conclusions of law, and impasition of discipline and the, Final Order of the Board

incorporating said Stipulation.

7. The Respondent waives {ha fight 10 seek any attorney‘s fees or 0051.5 from the

Dupartmenl in connection with this disciplinary pracaeding.

4 000637“

WHEREFORE, the parties hereto request the Board to enter a Final Order accepting and

implementing the terms contained herein.

Signed this L W/v;\day of m'¥w' , 1993.

Case Number 97-14067 (Signature must be notarized below)

Befor_e me, personally appeared F‘LDL— In Qrfl' whose identity is known to me by rLUL (type of ideniificalion) and who, under oath, aclmowiedgcs Ihai hislher

signature appears above.

Sworn to and subscribed by Respondent before me [his firfffday of {231mg , 1998.

fie“: a . mmr NOTARY PUBLIC

_ —,.

My Commission expires: “7/1 (5 '03-

Approved this 767//day of (2:7 7.2536110 , 1993.

Douglas M. Cook, LG .LHALBEHT

__ Director

nu

Duals Th1. un'r‘mm dermal

Chief Attorney Agency for Health Care

AdminieaLion

RDDx'cdr

000638



Petitioner,

vs.

JOSEPH P. MAR'UCA, Case No. 97-14067

Respondent. :’

ADMINISTRATIVE COMPLAINT

Petiiioner, DEPARTMENT OF HEALTH, hereinafter referred 10 as “Petiti(;ner,”

fits this Administrative Complaint before the Board of Massage against JOSEPH P.

MARUCA, hereinaficr referred to as “Respondent," and alleges:

1. Effective July I, 1997, Petitioner is the state agency charged with

regulating the practice of massage therapy pursuant to Section 20.43, Florida Statutes

(Supp. 1997); Chapter 455, Florida Statutas; and Chapter 480, Florida Statutes.

2. Pursuant to the authority of Section 2D.43(3){g), Florida Statutes (Supp.

1997), the Petitioner has conuacled with the Agfincy for Health Care Administration to

provide consumer complaint, investigative, and prosecutorial services required by the

Division pf Medical Quality Assurance, councils, pr boards, M appropriate, including the

issuance of emergency orders of suspension or restriction

3. Respondent is, and has been at all times material hereto, a licensed

massage therapist, having been issued liccnsa number MA 0002884.

000542

4. Respondem‘s last known address is 4340 NW 46th Terrace, Gainesville,

Florida 32606.

5. During the January 199? license renewal period, the Respondent

submitted fees for license renewal.

6. By submitting these fees, the Respondent was stating that by January 3 l ,

1997, he would have met all requirements for continuing education and I-HVJ'AIDS

course for the 1995-199?f biennium.

7. The Board of Massage Therapy conducted a continuing education audit of

licenses for the 1995—1997 biennium, requiring licensees to submit proof of completion of

the aforementiomd cuntinuing education. The Respondent‘s license: was sclecled for

audit.

8. Reslaondcni has failed to submit proof of the required HIWAIDS

education.

90m 9. Petitioner realleges and incorporates by reference the allegatiflns contained

in the foregoing paragraphs as if full}.r stated herein.

10. Based on the foregoing, the Respondent’s license to practice massage

therapy in the State of Florida is subject to discipline pursuant to Section 4556072 Florida

Statutes, by failing to meet the requirement for instruction on human immlmodcficiency

virus and acquired immlmc deficiency syndroma.

WREFORE, Petitioner respectfully requests the Board of Massage enter an

Order imposing One or more of the following penalties: imposition of an adminisirative

000643

fine not to exceed $1,000, issuance 0f a reprimand, placement of the Respondent on

probation, andfor any other rclicfthat the Board deems appropriate.

SIGNED this lgyday of NW ,1998.

Douglas M. Cook Director

NIH ‘ N c M S urkow kj m NTOFHE y- any - 5

DEPAD PUTYCLEHK av;q, Chkf Aflonmy

CLERK M On Behalf of the Agency for

Health Care Administration DATE

COUNSEL FOR AGENCY:

SusanB.BodelI 9'55 Senior Attorney Florida Bar Number 0937859

Agency for Health Care Administration General Counsel’s Office - MQA Allied Health 13.0. Box 14229

Taliahassee, FL 32317 — 4229

(350) 48?-9697

SBBRjeg

PCP: {QRJCL 4W?)

000644Lu

PRJZ‘F. CODE— LITTATION NU.

MA ..

DATE uF- COMPLAINT FE L E D 05:1w DEFApflEH-l CF HEALTH

CARI-2 .‘Il'MBER EPUTY “IL-EEK

1999-53225 CLERK Q 0pm., DATE

0‘5‘7'96" AGENCY FOR HEALTH CARE MJMINIS'I'RATIOS

“(mun OF M ASSAGE

UNlFORM DISCIPLINARY CITATION isslII-J) 1'0; J0¢iEI{HP. “WLRCA 43405 ACE:

GAINESVII. LE. I-1. 325m

LICENSE NUMBER IS}: MA mum-1

Puifiulml ID Swim-155.611 Ftnrida Smtmes {1991‘}. {mum}- Swim-155.314 [1991). IL»: uMerxigmd My ccrfifius IJJMI Irish:

has pmhable name lu helium;- IIIHI uh 11: “11: day of AUGUST, 1399. line pcrsmfis) whim: numufi} uppunr also“: did violate t.‘ ramming

[Instisim'm oflaw: “RMEIHH £- Board Rule MBT-ZMHJIR}

33' combining llu: Elwin: MKS}: SUBJECT FAILED TO PROVIDE PROOF THAT THE CONTINUING EDUCA’I'IGN

REQIIREA‘IENTS FUR. LICENSE. RENE‘NAL WERE MET AFTER BEING ELECTED FROM RANDOM AUDI-I“ SL'IUECT

FAILED TU PROVIDE I'RUUF OF THE CONTINUING EDUCATION HOURS FOR THE BIENNIL‘M 01" FEBRUARY 1, 1991'

THROUGH JANUARY 31. lm. PUP-Will"- lU Rule MIN—004mm» Florida Administrativt Codi. the Bum’fimy has 51:: th: fofliuw'mg penalty for violation of thc

aforesaid pmviuim.‘ $151331“! coals in tin: «main: of NJ]! Total amounl dun = $15.00

JSSI 7E.“ Ihir- 3‘" nf SEPI'EMBER 15m. RUBEN l. KL’iG-SHI‘LW JR.. EXECLTI'IVE DIRECTOR

[D No. HA l6

IF YOU DO NUT WSW: IF. THE CITATIOND AWITHK 'll-HR'H‘I 30 AU I'OMATIL fl] LY BEL CM] -5 A RNA]. ORDER OF '1 “EH .

TIL} \. invcsli Inn: and W WK]! I!“ [U H5 36F:- iii FUR {EFT IHI- 3R3 NEE-“31113 ,(Insumn HEIDI} railaEmswe F]. 31195. HY FFRTIFI'ED MA'II" ENCI. USING A l". OP‘I’ OFT.C1TA|‘EON.

NO'I YOU MAY F T TL! HAVE THESE (fl-MRGES FRUSECU'FIZD A5 A DISCIPLLNARY ACTION ACCORDING . . F1“. 4513‘ FLORmA STAT IFS. RATI'IFR THAN ACCEPT THIS CITATION.

In (in: even: Ilm ynu Elcct so have lhcsc charges 11mm“: pursuant to 5.45515, Plurida humws, HI: can: win 1:: pmwmcd Ia Lbs uppruprinll: pnbahle cause panel or II]: agar; f0: review. This wiil rank in a finding 01' whhahlc cause or no pm‘nl: cause.

DAY-i 0F SFRVICF THE (: ITA' FIUN . 01.! Ml 'S'F 30 S0

1' Servicc. rut. PM OWE-1: HEM

CHECK (1} l CHOOSE. TU PAY TIDE PENALTEES ON THE CITATION. ONE (2} I CHOOSE. NOT TO PAY TIEE CITATION. AND WISH TO HAVE THIS CASE PKWLTI'ED UNDER

3. 455.225, FL. STAT.

Signed '. Du: Sigmd JOSEPH P. MARI'CA

PLEASE. REM] REVERE»? SIDE OF THIS FORM

AHCAJ'REG FORM “15 1099

NOTICE

YOU HAVE A TOTAL OF SIXTY (60) DAYS FROM THE DATE THIS CITATION WAS SERVED UPON YOU '1' 0 PAY THE FIN-E AND COSTS SPECIFIED. THIS CITATION AUTOMATICALLY BECOMES A FINAL ORDER OF THE BOARD IF YOU DO NOT DISPUTE THE CITATION WITHIN THIRTY (30) DAYS OF THE DATE THIS CITATION WAS SERVED UPON YOU. AS A FTNAL ORDER! THE FINE AND COSTS SHALL BE DUE TO THE BOARD WITHIN THIRTY (30) DAYS OF THE DATE OF THE FINAL ORDER. AFTER THIS CITATION HAS BECOME A FLNAL ORDER, FAILURE TO PAY THE FINE AND COSTS SPECIFIED CONSTI’I‘LJTES A VIOLATION OF A FINAL ORDER OF THE BOARD, AND MAY SUBJECT YOU TO FURTHER DISCIPLINARY ACTION. PAYMENT SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION, Bureau of Reverme. Northwood Centre. 1940 North Monroe Street,

Tallahassee, Florida 32399-1006. PLEASE ATTACH A COPY OF THIS CITATION WITH YOUR PAYMENT.


I HEREBY CERTIFY than a true and correct copy of the foregoing Citation has been

served upon: JOSEPH P. MARUCA

Al: 4340 NW 46'“ TERRACE, GAINESVILLE, FL 32606

By Personal Serviuea’US. Certified Mail. Restricted Delivery. this 241“ day of SEPTEMBER. 1999.

Signalllre

.m muse. g. Wfl/ A.H.C.A. REPRESENTATIZ/E

’

NOTICE OF APPELLATE RIGHTS

This citalion becomes a Final Order ofthe Board if you have not contested it within thirty

(30) days of the date upon which the Citation was served upon you. II‘ this Citation becomes a

Final Order of the Beam. you have the right to appeal to the District Conn of Appeal in your area

or to the First District Conn of Appeal,

YOU ARE HEREBY NOTIFIED, pursuant to Seciion 120.59, Florida SLatuLes. and

120.68, Florida Statuzes. that you may appeal the Final Order by filing one copy of a Notice of Appeal with me Clerk of the Agency for Health Cam Administration, Nonhwood Centre. 1940

North Munme SmecL Tallahassee. Florida 32399—030. and by filing one copy of the Notice of Appeal and the filing fee (3 250.00, pursuant to Sec. 3522(3), Fiorida Statutes) with the District

Court of Appeal within thirty (30) days of the effective date of the Final Order.

July 26th 2016

To Who it may concern:

I have known Joe Maruca many years and have never known of him to be

anything but honest and professional in every way. I find no reason to deny him a

restoration of his Massage License. Please make sure this happens as soon as

possible.

an

y: émfé/fl #3,? N 35'; - WOW/023” 6M

July 26‘“ 2016

To Who it may concern:

] have known Joe Maruca many years and have never known ofhim to be

anything but honest and professional in every way. I find no reason to deny him a

restoration ofhis Massage License. Please make sure this happens as soon as

possible.

Thank you,

"/6746D1/f7/[444

jOk/cé Drudfi/W) HP ’55—

FLORIDA I


QUAN, SHIJIA DATE OF BIRTH: _ FILE NUMBER: 87414 COMPLETION DATE: 06/20/2016

Criminal History



Rick Scott Governor






August 12, 2016 File:87414

To: Shijia Quan

4561 Bell Blvd Bayside, NY 11361



Rick Scott Mission: To protect, prmme&inm/emehealm

,

Gwemor

gmgmwu‘ffiééegmd ‘ Celeste Philip, MD, MPH ’ '

HEALTH 3‘99” Gaee‘meae'ay

Vision: Tobe the Healthiest State in the Malian


August 12, 2016 File:87414

To: Shijia Quan 4561 Bell Blvd Bayside, NY 11361








Sincerely,

J '

,

.7

_

) ‘





P

of 5Date Created: Feb 26 2016 5:27PM




Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: SHIJIA QUANDate of Birth: 10/03/1963Place of Birth: CHINAEmail Address: [email protected]

Basic Data

Mailing Address4561 BELL BLVD BAYSIDE, NY 11361

Physical Location or Address of Employment4561 BELL BLVD BAYSIDE, NY 11361



Education History

School Name: OTHERSchool Name: BODYCONCEPTSchool Address: EAST RUTHERFORD, NJGraduation or Anticipated Graduation Date: 05/20/2012Total Number of Hours Completed: 630







Date Completed: 02/26/2016Course Name/Title: FL 10 HOUR LAW COURSE

Provider Number: 50-2554-4Provider/School Name: CEUONLINE



Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary3

H Vision: To be the Healthiest State in the Nation

Basic Data Profession: Application Type: Name: Date of Birth: Place of Birth: Email Address:

Mailing Address 4561 BELL BLVD BAYSIDE, NY 11361



Florida Departme

MASSAGE THERAPIST

nt of Health

INITIAL MASSAGE THERAPIST EXAM APPLICATION SHIJIA QUAN

COOLSH|J|A@HOTMA|L.COM

tsical Location or Address of Emplovment 4561 BELL BLVD BAYSIDE, NY 11361



Gender: Race:

Education Histom

917—346—1680



OTHER BODYCONCEPT EAST RUTHERFORD, NJ

05/20/201 2

630


Other Name Histozy








Provider Number: Provider/School Name: Course Name/Title: Date Completed:


50—2554—4

CEUONLINE FL 10 HOUR LAW COURSE 02/26/2016

Date Created: Feb 26 2016 5:27PM Page 1 of 5

I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B7—25.001(1)(f), F.A.C. Provider Number: 20—154894 Provider/School Name: CE FOR HEALTH CARE PROFESSIONALS Course Name/Title: PREVENTION OFMEDICAL ERRORS Date Completed: 02/26/2016

HIV/AIDS Course


Provider Number: 50—620 Provider/School Name: EXCELLENCE IN LEARNING Course Name/Title: HIV AIDS FOR INITIAL FL LICENSURE OR ENDORSEMENT Date Completed: 02/26/2016

Electronic Fingerprinting Record exists in the Florida Care Provider Background Screening Clearinghouse and may be eligible forthis application requirement.


Criminal Histogy

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Your answer: NO

Discipline HistoLy




Have you ever had a license or certificate of registration to practice massage therapy or Your answer: N0 any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in






Date Created: Feb 26 2016 5:27PM Page 2 of5
















Email Notification




Rick Scott Governor








March 8, 2016 Shijia Quan 4561 Bell Blvd Bayside, NY 11361


We have not received a passing score directly from the Federation of State Massage Therapy Boards (FSMTB). Please contact the FSMTB and have them release your score to our office. They may be reached at 1-866-962-3926 or at www.fsmtb.org. The background screening results received show “CHARGE” from DATE that was not disclosed on the application. Please provide the below documentation. (1.) A self-explanation describing the details of your criminal history written in your own words. If it is determined that your application must appear before the Board, this is what the Board will read. (2.) Documentation from the Clerk of Court in the county the offense occurred pertaining to the charge. This should include any arrest documentation, disposition of each charge and proof of successful completion of sentencing.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username quanshij and password ch82IEV3 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.

Rick Scott Mussmn:





March 8, 2016

Shijia Quan 4561 Bell Blvd Bayside, NY 11361

File No. 87414

Dear Applicant:







You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/m aservices/lo in.asp Once there, select your profession and enter your username *0 check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


P1NTEREST: Han/Fla

If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,

Katrina Hopkins Regulatory Specialist I


Sincerely, WW Katrina Hopkins Regulatory Specialist I

FLORIDA I


STEELE, SHELLEY EMMA DATE OF BIRTH: — FILE NUMBER: 88364 COMPLETION DATE: 08/16/2016

Criminal History **THE FOLLOWING IS DERIVED FROM AN ARREST RECORD AND PROVIDED

DOCUMENTS; CASE IS CURRENTLY OPEN“



Rick Scott Governor






August 16, 2016 File:88364

To: Ms. Shelley Emma Steele

8411 Fishhawk Avenue New Port Richey, FL 34653



Rick Scott Mussmn:




August 16, 2016 File:88364

To: Ms. Shelley Emma Steele 8411 Fishhawk Avenue New Port Richey, FL 34653








Sincerely,r

b J I,

V,

/ L17 / JANA

>





P





Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: MS. SHELLEY EMMA STEELEDate of Birth: 01/26/1971Place of Birth: ENGLANDEmail Address: [email protected]

Basic Data

Mailing Address8411 FISHHAWK AVENUE NEW PORT RICHEY, FL 34653

Physical Location or Address of Employment8411 FISHHAWK AVENUE NEW PORT RICHEY, FL 34653


Equal Opportunity DataGender: FEMALERace: BLACK

Education History

School Name: CORTIVA INSTITUTE - FLORIDA








Date Completed: 03/07/2016Course Name/Title: PEC121-B

Provider Number: 022796Provider/School Name: CORTIVA INSTITUTE - FLORIDA


Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. 3


Rick Scott Governor




Florida Department of HealthM Profession: Application Type: Name: Date of Birth: Place of Birth: Email Address:

Mailing Address 8411 FISHHAWK AVENUE NEW PORT RICHEY, FL 34653

tsical Location or Address of Emplovment 8411 FISHHAWK AVENUE NEW PORT RICHEY, FL 34653


ENGLAND

727—742—0793


Gender: Race:

FEMALE BLACK

Education Histom


Y EMMA STEELE

SSTEELE.LMT@GMA|L.COM

School Name: CORTIVA INSTITUTE -

FLORIDA School Address: Graduation or Anticipated Graduation Date: 06/04/2016 Total Number of Hours Completed: 750


Other Name Histozy








Provider Number: 022796 Provider/School Name: Course Name/Title: Date Completed:

PEC121—B 03/07/2016


Date Created: May 17 2016 8:25PM

CORTIVA INSTITUTE — FLORIDA

Page 1 of 5

I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B7—25.001(1)(f), F.A.C. Provider Number: 022796 Provider/School Name: CORTIVA INSTITUTE — FLORIDA Course Name/Title: RCR151—B Date Completed: 05/16/2016

HIV/AIDS Course


Provider Number: 022796 Provider/School Name: CORTIVA INSTITUTE - FLORIDA Course Name/Title: APP131—A Date Completed: 05/17/2016

Electronic Fingerprinting Record exists in the Florida Care Provider Background Screening Clearinghouse and may be eligible forthis application requirement.


Criminal Histogy

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Your answer: NO

Discipline HistoLy



























Email Notification




Rick Scott Governor





June 3, 2016 Ms. Shelley Emma Steele 8411 Fishhawk Avenue New Port Richey, FL 34653



Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username steelesh and password xWP6PQx6 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,



Gwemor

“a" Wei” Hm‘hmwimegm‘ed ‘ Celeste Philip MD MPH

stale,oaIny&oannnnyefims. ' ' '

HEALTH SIgeonGena‘el aMSaretay


June 3, 2016

Ms. Shelley Emma Steele 8411 Fishhawk Avenue New Port Richey, FL 34653

File No. 88364

Dear Applicant:




You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/m aservices/Io in.as Once there, select your profession and enter your usernamefim check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


Sincerely,

~

/ Gerry Nielsen Regulatory Specialist II



P H A B

FLORIDA |


WAN G, YU EXIA

DATE OF BIRTH: _ FILE NUMBER: 88903 COMPLETION DATE: 08/11/2016

School approved by California Bureau of Private Postsecondary Education

Disciplinary History

Previous License: MA67638 Case Number: 2012-13868 Date of Final Order: 01/29/2013 Current Status: DISCP-RELINQ



Rick Scott Governor






August 12, 2016 File:88903

To: Yuexia Wang

2679 N Glenside St Orange, CA 92865



Rick Scott Mussmn:




August 12, 2016 File:88903

To: Yuexia Wang 2679 N Glenside St Orange, CA 92865








Sincerely,

J r

,

.,

fLU/ fig _

j ‘





P

Rick Scott

Celeste Philip, MD, MPH SurgeonGeneral and Secretary

Governor


Mission:To protect, promote & improve the healthof all people in Florida through integratedstate, county & community efforts.


Application Summary

Application DetailLicense Type: Massage Therapist

Profession Number: 1401 - Massage Therapist

File Number: 88903

Application: Massage Therapist by Examination

Application Date: 07/07/2016

Application QuestionsMilitary Veteran Fee Waiver - I have beenhonorably discharged from a branch of theUnited States Armed Forces within theprevious 60 months.

No

Military Veteran Spouse Fee Waiver - I amthe spouse of a military veteran who hasbeen honorably discharged from a branch ofthe United States Armed Forces within theprevious 60 months.

No

Personal DetailFirst Name: Yuexia

Last Name/Surname: Wang

Birthdate: 04/06/1959

Gender: Female

Race: Asian

Social Security Number: *****7990

Addresses Main Address Address: 2679 N Glenside St

Out of State

Orange, CA

92865

US

Phone Number:

Page 1 of 67/7/16 10:45 PM


HEALTH

Rick Scott Governor




Application Summary

Application Detail License Type:

Profession Number:

File Number:

Application:

Application Date:

Application Questions Military Veteran Fee Waiver - I have been honorably discharged from a branch of the United States Armed Forces within the previous 60 months.

Military Veteran Spouse Fee Waiver - I am the spouse of a military veteran who has been honorably discharged from a branch of the United States Armed Forces within the previous 60 months.

Personal Detail First Name:

Last Name/Surname:

Binhdate:

Gender:

Race:

Social Security Number:

Addresses Main Address

Address:

Phone Number:

7/7/1610:45 PM

Massage Therapist

1401 - Massage Therapist

88903

Massage Therapist by Examination

07/07/2016

No

No

Yuexia

Wang

Female

Asian

2679 N Glenside St

Out of State

Orange, CA

92865

US

Page 1 of 6

Extension:

E-mail Address:

Physical Location Address:

[email protected]

NOT PRACTICING

Education History Massage School:

Date of Graduation or Anticipated Graduation (mm/dd/yyyy):

Total Number of Hours Completed (Please use numbers only with no decimals (example 200):

Institution Name:

CALIFORNIA APPROVED PROGRAM

02/29/2016

675

Lincoln Institute of Body Therapy

I authorize the schoo|(s) listed above to release my official Yes transcript(s) directly to the Florida Board of Massage Therapy.

Other State Licenses Do you now hold or have you ever held a license to practice Yes Massage Therapy or any other profession in any US State or territory, or foreign country?

License Number:

Type:

Original Date Issued:

Date of Expiration:

Country:

State:

007092

Massage Therapist

01/11/2012

04/30/2017

UNITED STATES

Conneticut

7/7/1610:45 PM Page 2 of 6

Mandatory Continuing Education Have you completed a three hour course on HIV/AIDS as Yes required by Florida Statute?

Provider Number: 432729-00

Provider/School Name: Apollo Correspondence Classes

Course Number/Title: Florida HIV and AIDS


Ten Hour Florida Laws and Rules Course As a condition of licensure, you must complete a ten hour Florida laws and rules course administered by a Florida Board approved school or a Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. I have completed a ten hour Florida laws and rules course as Yes defined in rule 6487-32003, F.A.C.

If you have completed this requirement as part of your curriculum, please list your school in the "Provider/School Name" field and your graduation date in the "Date Completed" field below. Likewise, if you completed this requirement as an apprentice, list the name of your sponsor in the "Provider/School Name" field and your apprentice completion date in the "Date Completed" field. Provider Number: 432729-00

Provider/School Name: Apollo Correspondence Classes

Course Number/Title: 10 Hours of Florida Laws and Rules

Date Completed: 07l07/2016

Criminal History Have you EVER been convicted of, or entered a plea of guilty, Yes nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld.

7/7/1610:45 PM Page 3 of 6

Reckless driving, driving while license suspended or revoked (DWLSR), driving under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses for purposes of this question. Date of Offense:

Offense:

Pleading Type:

Adjudication:

State or Jurisdiction:

Applicant Statement:

Discipline History - Denial

06/16/2008

Disorderly Conduct

Guilty

Guilty

New York

The date of the first incident was on March 05, 2008. The specific charge convicted of is unauthorized practice of profession. The court dismissed the charge due to a conviction on docket 20088U031826, which is a disposition for the second incident. The date for the second incident is on June 16, 2008. The specific charge convicted is disorderly conduct, of which I pled guilty. The court placed me on one year conditional discharge as well as a fine of $500, of which I

paid. Both Incident occurred in Suffolk, New York. I have not violated any laws since the date of violation of this case, which was 8 years ago. I have complied with all the terms of charge. I

am not currently serving a sentence for any offense, nor on probation for any offense, nor under charge of commission of any crime. Moreover, since the end of my offense I have lived an honest and upright life. At the time, I had just immigrated to the United States and I did not fully understand the consequences and irresponsibility of my actions. Future occurrences will not occur because I am now assimilated into the American culture and I understand U.S. laws. I realize now that what I had done in the past was wrong and that nothing is worth me compromising my integrity. Furthermore, the state of Connecticut has realized this and has granted me a massage therapist license on 01/11/2012. Therefore, I am asking the board to disregard my criminal history and grant me a massage therapist license so that I can continue to work in the industry that I

love.

Have you ever been denied or is there now any proceeding to No deny your application for any healthcare license to practice in Florida or any other state, jurisdiction or country?

7/7/1610:45 PM Page 4 of 6

Discipline History - Surrender Have you ever surrendered a license to practice any healthcare related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?

Discipline History - Disciplined Have you ever had disciplinary action taken against your license to practice any healthcare related profession by the licensing authority in Florida or in any other state, jurisdiction or country?

Discipline History - Pending Do you have disciplinary action currently pending against any license?

Medicaid/Medicare (Applicants) 1. Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction?

2. Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. 55. 801-970 (relating to controlled substances) or 42 U.S.C. 55. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)?

3. Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes?

4. Have you ever been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program?

5. Are you currently listed on the United States Department of Health and Human Services Office of Inspector General‘s List of Excluded Individuals and Entities?

Electronic Fingerprinting I have been provided and read the statement Yes from the Florida Department of Law Enforcement regarding the sharing, retention, privacy and right to challenge incorrect criminal history records and the 'Privacy Statement‘ document from the Federal Bureau of Investigation.

Enter in today's date 07/07/2016

Availability for Disaster Are you willing to provide health care services in special need shelters or to work with disaster medical teams during times of emergency or major disasters?

7/7/1610:45 PM

No

No

No

No

No

No

No

No

Yes

Page 5 of 6

If you respond 'Yes', your name will be added to a data listing that is available to the Department of Health if a disaster is declared. If you live in an area where you may be able to help you will be called on if needed. Fees Application Fee $50.00

Initial License Fee $100.00

Unlicensed Activity $5.00

Total Amount Due: $155.00

Attestation

I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has been submitted if and when any material change in circumstances or conditions occur which might affect the Boardgls decision concerning my eligibility for examination or licensure. Such supplement is required by Section 456.013(1), F.S. Failure to do so may result in disciplinary action by the Board including denial of licensure.

I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare that my answers and all statements made by me herein and in support of this application are true and correct. Should I furnish any false information on or in support of this application, I understand that such action shall constitute cause for denial, suspension, or revocation of any license to practice in the state of Florida in the profession for which I am applying. I hereby acknowledge that practice as a licensed Massage Therapist in Florida is governed by Chapters 456 and 480, Florida Statutes, and Rule Chapter 64B7, Florida Administrative Code. I understand that I am under a continuing obligation to understand and keep informed of any changes to Chapters 456 and 480, F.S., and Rule Chapter 6437, Florida Administrative Code.

7/7/1610:45 PM Page 6 of 6

certificate of Achievement awarded to

YUEXIA WANG Licensed: -

having sucessfully completed 16 continuing education hours in

FLORIDA INITIAL LICENSING PACKAGE

On July 8, 2016

Course Numbers(s): FL 20-427216

Massage Continuing Education Provider Approvals:

NCBTMB Provuder #432729-00. Florida Provider “50-8479 New York State Education Department’s State Board for Massage Therapy Provider #1031

Texas Provider #CE1716

Apollo Correspondence Classes

21162 Banff Lane

Huntington Beach, CA 92646 Email: go@apo||0123.com

Phone: 866-506-1999

Shirley Henderson Director/Instructor of Online Study

Certificate Number: AVR874 Includes:

3 hours Prevention 0' Medical Errors

3 hours a! Florida HIV and AIDS

10 hours of Florida Law and Rules

Final Order No. DOH-13-0101- -MQA

FILED DATE JAN 2 9 2013 Depart nt of Health

By:

uty AgencY Clerk



Petitioner,

VS. Case No.: 2012-13868 License No.: MA 64258

YUEXIA WANG,

Respondent.

FINAL ORDER

THIS CAUSE came before the BOARD OF MASSAGE THERAPY (Board)

pursuant to Sections 120.569 and 120.57(4), Florida Statutes, on

January 24, 2013, in Sunrise, Florida, for consideration of

Respondent's voluntary relinquishment (attached hereto as Exhibit

A). Petitioner has filed an Administrative Complaint seeking

disciplinary action against the license. A copy of the

Administrative Complaint is attached to and made a part of this

Final Order as Exhibit B. Upon consideration of the voluntary

relinquishment, the documents submitted in support thereof, the

arguments of the parties, and being otherwise fully advised in

the premises, it is hereby

ORDERED AND ADJUDGED that the voluntary relinquishment is

accepted as a resolution of this case.

This Final Order shall take effect upon being filed with the


Final Order No ~Dou.u.om._ g ‘MQA Fll.‘ ‘

BOARSTSEEMgisiggRiaémy By

%E?”EZQ:TEL53WU’3

DEPARTMENT OF HEALTH, "9 'Mgenmrm

Petitioner,

vs. Case No.: 2012—13868 License No.: MA 64258

YUEXIA WANG,

Respondent./

FINAL ORDER

THIS CAUSE Came before the BOARD OF MASSAGE THERAPY (Board)

pursuant to Sections 120.569 and 120.57(4), Florida Statutes, on

January 24, 2013, in Sunrise, Florida, for consideration of

Respondent's voluntary relinquishment (attached hereto as Exhibit

A). Petitioner has filed an Administrative Complaint seeking

disciplinary action against the license. A copy of the

Administrative Complaint is attached to and made a part of this Final Order as Exhibit B. Upon consideration of the voluntary

relinquishment, the documents submitted in support thereof, the

arguments of the parties, and being otherwise fully advised in

the premises, it is hereby

ORDERED AND ADJUDGED that the voluntary relinquishment is

accepted as a resolution of this case.

This Final Order shall take effect upon being filed with the


DONE AND ORDERED this 7/474? day of 2013.

BOARD OF MASSAGE

41"..■

0111111P

Ant/n y J vitch, Ex:/utive Director for K.,en Goff Ford Chair



foregoing Final Order has been provided by U.S. Mail to YUEXIA

WANG, 43-40 Union Street #1K, Flushing, NY 11355; and by

interoffice delivery to Lee Ann Gustafson, Senior Assistant

Attorney General, Department of Legal Affairs, PL-01 The Capitol,

Tallahassee, FL 32399-1050, and by interoffice delivery to

Cecilie Sykes, Assistant General Counsel, Department of Health,

4052 Bald Cypress Way, Bin C-65, Tallahassee, Florida 32399-3265

this 2.ail A-4-) day of 2013.

SCIACkkho

Deputy Agency Clerk

2 Case No. 2012-13868

2:2? g g

: DONE AND ORDERED this day of ,

2013.

BOARD OF MASSAGE

THEE;

Ant ny J vitch, Ex utive irector for K en Goff Ford Chair



foregoing Final Order has been provided by U.S. Mail to YUEXIA

WANG, 43—40 Union Street #1K, Flushing, NY 11355; and by

interoffice delivery to Lee Ann Gustafson, Senior Assistant

Attorney General, Department of Legal Affairs, PL—Ol The Capitol,

Tallahassee, FL 32399—1050, and by interoffice delivery to

Cecilia Sykes, Assistant General Counsel, Department of Health,

4052 Bald Cypress Way, Bin C—65, Tallahassee, Florida 32399—3265

this 2F1t4q day of ; g 3:} gglgj

l

, 2013.

Deputy Agency Clerk

Case No. 2012—13868

STATE OF FLORIDA'


DEPUTY CLERK CLERK Angel Sanders DATE NOV 01 2012

4901 XVI 85:01 81.00110/00


DEPARTMENT OF HEALTH, Petitioner,

v. DOH Case. No. 20i2438611,'"',

YUEXIA WANG, Respondent

VOLUNTARY RELINQUISHMENT OF LICENSE

Respondent YUEXIA WANG, L.M.T., License No. MA 64258, hereby

voluntarily relinquishes Respondent's license to practice Massage iribegateof

Florida and states as follows:

I. Respondent's purpose In executing this Voluntary ReliOqUishOrient is

to avoid further administrative action with respect to this cause. Respondent

understands that acceptance by the Board of Massage Therapy (hereinafter the

Board) of this Voluntary Relinquishment shall be construed as disciplinary

action against Respondent's license pursuant to Section 456.0Z241)(41xida.i

Statutes. i i • '

2. Respondent agrees to voluntarily cease pra

therapy immediately upon executing this Voluntary

Respondent further agrees to refrain from the practice of

•

i". " ‘ ' y. <

3" '

DEPARTMENTOF HEALTH DEPUTY CLERK

CLERK Angel Sandal-s STATE OF FLORIDA 0*"

NOV 0 1 zmz BOARD OF MASSAGETHERAPY

DEPARTMENT OF HEALTH, -; Mum" ,

'. u . . ‘ ié'fif“l:.-=‘.§§":I"‘..'.‘|i'li gh'

v. - - - '

DOH'Case-No;zen-@3858»??? ' I

YUEXIAWANG, - -

- ~ ‘

; . .: 2;: -. " Respondent.

-

, .

- j . . Iv, » “gnaw

Respondent YUEXIA WANG, L.M.T., License No. MA [54258, hereby

vofuntarily relinquisha Rapondent’s license to practiceMamg’a ln‘HIé‘St‘af

Florida and states as follows: ‘

1 , 1’ i”

_

1. Respondent’s purpose In executing this Voluntary Wis . ._ “I:

to avoid further administrative action with respect a: this cause. Respondent'

understands that atmptanoe by the Board of Massage Therapy (hereinafluer the

Board) of this Voluntary Relinquishment shall be construed a's disdpllnarv

action against Respondmt’s license pursuant to Section 456.01.21(1)(f),3flpfldaz -- ,

.

Statutm 1’

!_

' ‘

' ' I

2. Respondent agrees to voluntarily cease .. .

therapy immediam upon executing this Voluntary

Respondent further agrees to refraln from the pradice of _

;

M

....... I! IV! 8550! slot/vol»

until such time as this Voluntary Relinquishment Is -preteerbitiftrithilriabilinihi•

and the Board issues a. written final order in.this matter'. '

3. In order to expedite consideration and resolutionotittisalltkra brifj.;i;

the Board In a public meeting, Respondent, being' fullyqkpisedi Ann

consequences of so doing, hereby waives ..tile stabil:0qt: privileitfof

confidentiality of Section 456.073(10), Florida Statutes, aid

determination of probable: cause - by • the. Probable-. CauseRameligibrultit

Department when appropriate, :! pursuant-. to . Section . 456,073()?1110oolda

Statutes, regarding the complaint, the investigative:report oftha:Deairtineht

of Health, and all -other information obtained pursuant tolhoiDepartment's

Investigation in the above-styled action. By signing this warier, Responder* ,1

understands that the record and complaint become public record and remain

public record and that information is immediately accessible to the public:4►

Section 456.073(10) Florida Statutes,

4. Upon the Board's acceptance of this Voluntary.

Respondent agrees to waive all rights to seek Judicial

challenge or contest the validity of, this Voluntary Rellnq

Final Order of the Board incorporating this Voluntary Rel

DOH v. YUEXIA WANG, LMT, Cass No. 2012-13868

Met /011/11

4902 mm Iona a

until such time as this-Voluntary Refin'qulshment Is-presaxuaftdzmrpum3é7

and the Board Iss‘ues awritten final order in-mis matter; - "m: ;i.:‘.‘,;.i.:.-¥ 12x: ,

)

3. In order to apedlte considetafion and resolufimufrtfibm b] 4; .j

:A‘

the Board In a‘ public meeting, Respondent, being 1%u mm .1 y [it consequenm of so doing, hereby waives. the tflwflqf?

'l

determination of probable muse, by the Probable. Causelfineifiimme "'

Department when appropriate,;fpursuanti~.to: Section 456:0743Mmm

confidentiality of Section 456. 073(10), Florida Statutes, aha way-s n+7: V

"

Statutes, regarding the coniplalnt, the Imestigative-‘zépon (#11330t of Health, and all 'other information obtained purshant mVflIaampamt's.

Investigation in the above—styled action. By signing this waiter, Respondent 1|, -

understands that the record and complaint become publk: recon! and remalli I I

public record and mat Information is immedlately accesslblé to the mm Section 456117300) FIorlda'Statutm. ‘

‘ .

-‘. ~ - ‘.

4. Upon the Board‘s acceptance of this Voluntary "

I .

Respondentagreeshomlveall ngmsmseekmual my challenge or oontst the valldlty of, this Volunhry Rdhq ._ »

I

Final Order of the Board incorporating this Voluntary Rd -

DON v. YUEXIA WANG, LHT, me No. 1012-1353

.—4902—

•

5. Petitioner and RespOndent hereby agree that ,upopf the4o8rdt0;;11:011:

acceptance of this Voluntary Relinquishment, each party shilliybkiat'. own .• . ' ." attorney's fees and costs related to the prosecution or defense ofthis matfle.

I.: .• • 6. Respondent authorizes the Board to review .:.and examine aU

I .

that consideration of this Voluntary Relinquishment and other relibXi . . ;

by the Board shall not prejudice or preclude the Boardo, or anyfddtp,meriltieRy • •.

.. .•. a .

• ., — investigative file materials concealing Respondent contiection with the • •.:i •

.0;k•11 Board's consideration of this Voluntary Relinquishment RetOtOdeiti"

from further participation, consideration, or resolution .of these mroc:eedp if , • '," ; . the terms of this Voluntry Relinquishment are not accepted

DATED this 15 411 day of 00-0.

STATE OF fttelitiDA HEM/ ORK COUNTY OF au F,."--i\ts

Before me, personally appeared #4013 drir laVletritype identity is known to me by 40._

and who, under oath, acknowledges that his/her

Sworn to and subscribed before me this 1514')day of

GIACCHINO J. RUSSO Nato/ PAID, sad$ bpk New

No. 02RU4K4109 Ogolifisci in Wocinhoilor

Coons/Jon Eqinio Jansioryerre. DOH v. YUE)UA WANG, 114T, Case No. 2012-13868

tan ia

-4903


5. Petitioner and Rspbndent hereby agree that upon the 803M“;~

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6. Respondent authorizes the Board tn review; ;-and mine a ~«O4‘o—W—

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investigative file materials concerning Rsmndent in connection MEI" they

Board's consideration of this Voluntary Rellnqulshnmt. W; that oonslderation of this Voluntary Rellnqulshment and other lelalnd

.

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by the Board shall not prejudice or preclude. the Board :9: anyLdf 1t§

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from further parfidpaflon, consideafion or resolution of mm '

the terms of this Voluntary Reflnqmshment are not 'adoemd W303“ DATEDU1Is’54hdayof Qs'Obé/V‘ g'2w012._-;“

mm mm NEW 012K '

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COUNTY OF: .' A

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Before me, personally appeared ’ ‘K I

ldentityisknowntom [1"m

STATE OF FLORIDA


INVESTIGATIVE REPORT

Office: TALLAHASSEE INVESTIGATIVE SERVICES

Date of Complaint: September 19, 2012

Case Number: MA 2012-13868 •

Subject: YUEXIA WANG, LMT 43-40 Union Street, Apt. 1K Flushing, NY 11355 212.-518-8182

Complainant/Source: DEPARTMENT OF HEALTH

Prefix: MA

Licence #: 64258

Profession: Massage Therapist

Board: Massage Therapy

Report Date:

September 20, 2012 Period of Investigation: September 19, 2012 through September 20, 2012

Type of Report: FINAL

Alleged Violation: §456.072(1)(h)(m)(w), F.S., §480.047(1)(f), F.S. and §480.046(1)(o), F.S.: "Attempting to obtain, obtaining, or renewing a license to practice a profession by bribery, by fraudulent misrepresentation, or . ..." "Making deceptive, untrue, or fraudulent representations in . .. "Give false or forged evidence to the department in obtaining any license provided for herein." "Failing to comply with the requirements for profiling and credentialing ...." and Violating any provision of this chapter or chapter 456, or ...." Synopsis: This investigation is predicated on a complaint from DEPARTMENT OF HEALTH alleging that on

submitted fictitious documents from the Florida College of Natural Health (FCNH) with her license to practice massage therapy. With the application, WANG provided fictitious

certificate of completion of the Therapeutic Massage Training Program from the Florida Health. On July 20, 2011, the Department issued a license to practice massage therapy to time the Department was not aware that the documents submitted in support of WANG'S

An authorized representative of the Florida College of Natural Health attested that that institution and/or did not obtain the credits provided in the fictitious documents. (Ex.

notified of this complaint by letter dated September 19, 2012 to the address on file with a copy of the case summary, initial complaint, and a Voluntary Relinquishment of License

computer information indicates that WANG is licensed as a Massage Therapist in the a license status of clear and active.

identified, thus patient notification was not required. -.1-;..

RI r ?*7

to be represented by an Attorney. 1\3 . ri

has been no contact with, or response from, WANG. C'' r

pi C'-';

June 6, 2011 WANG application for a Florida transcripts and a College of Natural WANG and at that application were fictitious. WANG did not attend #1)

WANG was therefore the Board including form. (Ex. #3)

As of this date, DOH State of Florida with

No patient(s) was/were

WANG is not known

At this time, there

Related Case: none r.... 9t, rr-I

lnves igat• /Date:

-.4 Jo • • • : e em r , 2012

vestigation Specialist II CI-55)

,C■ , r--

C-) Approved By/Date: A . . . 0 .,- . . . i . ' 4

Received g ooksey, vestigation ManagagewegoveServices

Distribution: Prosecution Services Unit/Investigative Services Unit SEP 21 2017

4924 •

DON/MQA Tallahassee HQ

STATE OF FLORIDA


INVESTIGATIVE REPORT

Office: TALLAHASSEE Date 0* C°mP'3‘"'~' Case Number: INVESTIGATIVE SERVICES September 19. 2012 MA 2012-13868 Subject:

Complainant/Source YUEXIA WANGl LMT A N '

EALTH 43-40 Union Street, Apt. 1K DEP RTME T OF H

’ 355

Prefix: Licence #: Profession: Board: Report Date: MA 64258 Massage Therapist Massage Therapy September 20' 2012 Period of Investigation:

'

Type of Report: September 19, 2012 through September 20. 2012 FINAL Alleged lafion: §456.072(1)(h)(m)(w). F.S.. 5450.047(1)(f). F.S. and §480046(1)(o). F.S‘: “Attempting to obtain, obtaining. or renewing a license to praajce a profession by bribery. by fraudulent misrepresentation, or . ,

..' ”Making deceptive, untrue. or fraudulent representafions in . . 'Give false or famed evidence to the department in obtaining any license provided for herein.‘ “Failing to comply with the requirements for profiling and credentialing . . .A' and “Violating any provision of this chapter or chapter 456, or . . ..' Synopsis: This investigation is predicated on a complaint from DEPARTMENT OF HEALTH alleging that on June 6, 2011 WANG submitted ficfitious documents from the Florida College of Natural Health (FCNH) with her application for a Florida license to practice massage therapy; th the application, WANG provided fictitious transcripts and a certificate of completion of the Therapeutic Massage Training Program from the Florida College of Na‘ural Hearth. -On July 20. 2011, the Department issued a license to practice massage therapy to WANG and at that time the Department was not aware that the documents submitted in support of WANG's application were fictitious. An authorized representative of the Florida College of Natural Health attested that WANG did not attend that institution and/or did not obtain the credits provided in the fictitious documents. (Ex. #1)

WANG was therefore notified of this complaint by letter dated September 19. 2012 to the address on file with the Board including a capy of the case summary. initial complaint, and 3 Voluntary Relinquishment of License form. (Ex. #3)

As of this date, DOH computer information indicates that WANG is licensed as a Massage Therapist in the State of Florida with a license status of clear and active.

No patient(s) was/Were identified, thus patient notification was not required. 76' .2: Co ,. n, ”'7

WANG is not known to be represented by an Attorney. ,3” fir? *5 '6

At this time, there has been no contact with, or response from. WANG. f P? Related Case: none '

a: f: c; Inve igat /Date: Approved Blate: If: ’5

9 4,0 ‘ l 7/ Jo

1 r . 2012 Ma vestigation Specialist II cu-ss) Jim ooksey. vestigatlon Whammy-mam Distn‘bufion: Prosecution Services Unit/Investigative Services Unit SEP 21 2mg

DOWMOA Til-Maurie 4924

Final Order ‘10 ‘ .DOli-l2-20§_ ‘ FILED m n: .‘9/2é/201F250 ' Mm

._ De an...“l ., \< STATE OF FLORIDA ”Wes/L

DEPARTMENT OF HEALTH "M

IN RE: The Emergency Suspension of the License of Yuexia Wang, L.M.T. License Number: MA 64258 Case Number: 2012—13868

ORDER OF EMERGENCY SUSPENSION OF LICENSE

John H. Armstrong, MD, State Surgeon General and Secretary of

Health, ORDERS the Emergency Suspension of the license of Yuexia Wang,

L.M.T. (“Ms. Wang"), to practice as a massage therapist in the State of

Florida. Ms. Wang holds license number MA 64258. Her address of record

is 43-40 Union Street, Apartment 1K, Flushing, New York 11355. The

following Findings of Fact and Conclusions of Law support the Emergency

Suspension of Ms. Wang’s license to practice as a massage therapist in the

State of Florida.

INTRODUCTION

In June 2011, Ms. Wang submitted an Application for Licensure as a

massage therapist with the Florida Department of Health Board of Massage

Therapy (“Florida Board”). The application included documentation

indicating that Ms. Wang completed courses and received Certificates of

Completion from Florida College of Natural Health. In July 2012, the Vice

In Re: Emergency Suspension of the License of Yuexia Wang, L.M.T. License No.: MA 64258 Case No.: 2012—13868

President of Compliance and Institutional Effectiveness of Florida College of

Natural Health certified that the documentation submitted by Ms. Wang

purporting to be from the Florida College of Natural Health is fraudulent.

FINDINGS OF FACT

1. The Department of Health (“Department") is the state agency

charged with regulating the practice of massage therapy pursuant to

Chapters 20, 456, and 480, Florida Statutes (2012). Section 456.073(8),

Florida Statutes (2012), authorizes the State Surgeon General to summarily

suspend Ms. Wang’s license to practice as a massage therapist in the State

of Florida pursuant to Section 120.60(6), Florida Statutes (2012).

2. On June 6, 2011, Ms. Wang submitted a State of Florida

Application for Licensure as a massage therapist to the Florida Board.

3. On her Application for Licensure, Ms. Wang indicated that she

attended the Florida College of Natural Health. Supporting documentation

for the application, however, shows that Ms. Wang received her massage

therapy training at the Professional School of Massage in Langhorne,

Pennsylvania. The Professional School of Massage is not a Florida Board

In Re: Emergency Suspension of the License of Yuexia Wang, L.M.T. License No.: MA 64258 Case No.: 2012-13868

approved school. Ms. Wang’s Application further reveals that Ms. Wang did

not attend an apprenticeship program.

4. Pursuant to Section 480.041(1)(b), Florida Statutes (2011), in

order to qualify for Iicensure as a massage therapist in the State of Florida

pursuant to Chapter 480, Florida Statutes, a person must complete a

course of study at a board-approved massage school or complete an

apprenticeship program that meets the standards adopted by the board.

5. Submitted to the Florida Board with Ms. Wang’s Application for

Licensure was a transcript from Florida College of Natural Health

representing that Ms. Wang earned five hundred credit hours in the Florida

College of Natural Health Therapeutic Massage Training Program (Transfer

of Licensure). The transcript indicates that Ms. Wang started the program

on June 27, 2011, and completed the program on July 8, 2011.

6. Ms. Wang also submitted, with her Application for Licensure, a

Florida College of Natural Health Certificate of Completion of 35 hours of

Therapeutic Massage Training Program (Transfer of Licensure) dated July

8,2011.


7. Also submitted with Ms. Wang’s Application for Licensure was a

Florida College of Natural Health Certificate of Completion of two hours of

Prevention of Medical Errors dated July 1, 2011.

8. On July 19, 2012, the Vice President of Compliance and

Institutional Effectiveness for Florida College of Natural Health (“V.P.”)

certified that the Florida College of Natural Health transcript Ms. Wang

submitted with, and in support of, her Application for Licensure is

fraudulent. In addition, the V.P. certified that Ms. Wang did not complete

the courses identified in the certificates Ms. Wang submitted with, and in

support of, her application for licensure.

9. Having not completed courses at, or obtained certificates of

completion from, a Board of Massage Therapy approved school, as

required by Section 480.041(1)(b), Florida Statutes (2011), Ms. Wang is

not qualified to be licensed, or to practice, as a massage therapist in the

State of Florida.

10. Section 480.046(1)(o), Florida Statutes (2011), subjects a

massage therapist to discipline, including suspension, for violating any


provision of Chapters 480 or 456, Florida Statutes, or any rules adopted

pursuant thereto.

11. Section 456.072(1)(h), Florida Statutes (2011), subjects a

massage therapist to discipline, including su5pension, for attempting to

obtain, obtaining, or renewing a license to practice a profession by bribery,

by fraudulent misrepresentation, or through an error of the department or

the board.

12. Section 456.072(1)(w), Florida Statutes (2011), subjects a

massage therapist to discipline, including suspension, for failing to comply

with the requirements for profiling and credentialing, including, but not

limited to, failing to provide initial information, failing to timely provide

updated information, or making misleading, untrue, deceptive, or

fraudulent representations on a profile, credentialing, or initial or renewal

licensure application.

13. The State Surgeon General has jurisdiction over this matter

pursuant to Sections 20.43 and 456.073(8), Florida Statutes (2012), and

Chapter 480, Florida Statutes (2012).


14. Section 120.60(6), Florida Statutes (2012), provides that the State

Surgeon General is authorized to suspend or restrict a massage therapist’s

license upon a finding that the massage therapist presents an immediate,

serious danger to the public health, safety, or welfare.

15. Ms. Wang obtained her license to practice massage therapy in the

State of Florida by fraud. Ms. Wang submitted an application for licensure

to the Florida Board indicating she completed courses through the Florida

College of Natural Health. At the time she submitted her application, Ms.

Wang was aware that she had not completed these courses through the

Florida College of Natural Health. She also knew she had not actually

satisfied the requirements for graduation from a Florida Board approved

school. Through her action of submitting a fraudulent license application to

the Florida Board, Ms. Wang has demonstrated a willingness to circumvent

the regulations, requirements, and laws governing massage therapists in

the State of Florida. She also demonstrated judgment and moral character

that is exceedingly poor and unbefitting of a licensed massage therapist.

16. Aside from her fraudulent conduct, Ms. Wang has not satisfied the

fundamental education requirements to be licensed as a massage therapist


in the State of Florida. These requirements were carefully crafted by the

Florida Board to ensure the competency of licensed massage therapists and

to protect the public from unqualified massage therapists. Because Ms.

Wang circumvented these fundamental education requirements, her clients

are at risk for potential injury due to improper massage technique.

17. Moreover, clients of massage therapists are placed in isolated,

vulnerable settings where they can be subject to abuse by their massage

therapists. Due to the potential for abuse that is inherent under these

circumstances, massage therapists must possess good judgment and good

moral character in order to safely practice massage therapy. Ms. Wang’s

willingness to circumvent the licensure requirements of the State of Florida

demonstrates a defect in Ms. Wang’s judgment and moral character.

18. Ms. Wang’s conduct demonstrates such a disregard for the laws

and regulations governing massage therapists in this state, and constitutes

such a threat to the public health, safety, or welfare, that the safety of Ms.

Wang’s clients cannot be assured as long as she continues to practice

massage therapy in the State of Florida. Ms. Wang's disregard for the laws

and rules governing the practice of massage therapy and her lack of good


judgment and moral character represent a significant likelihood that Ms.

Wang will cause harm to clients in the future. This probability constitutes

an immediate, serious danger to the health, safety, or welfare of the

citizens of the State of Florida. Nothing short of the suspension of Ms.

Wang’s license to practice as a massage therapist in the State of Florida

will protect the public from the dangers created by Ms. Wang.

CONCLUSIONS OF LAW

Based on the foregoing Findings of Fact, the State Surgeon General

concludes as follows:

1. Ms. Wang violated Section 456.072(1)(h), Florida Statutes (2011),

by obtaining her license to practice massage therapy in the State of Florida

through error of the Department or by fraudulent misrepresentation by

submitting a fraudulent transcript and fraudulent Certificates of Completion

with her Application for Licensure as a massage therapist in the State of

Florida.

2. Ms. Wang violated Section 456.072(1)(w), Florida Statutes (2011),

by submitting a fraudulent transcript and fraudulent Certificates of


Completion with her Application for Licensure as a massage therapist in the

State of Florida.

3. The facts recited above support the conclusions that Ms. Wang is

unable to safely practice massage therapy due to her having obtained a

license to practice massage therapy by fraud and that a restriction of Ms.

Wang’s license to practice massage therapy in the State of Florida is not

sufficient to protect the health, safety, or welfare of the public.

4. This summary procedure is fair under the circumstances to

adequately protect the public.

WHEREFORE, in accordance with Section 120.60(6), Florida Statutes

(2012), it is ORDERED THAT:

1. The license of Yuexia Wang, L.M.T., license number MA 64258, is

hereby immediately suspended.

2. A proceeding seeking formal suspension or discipline of the license

of Yuexia Wang, L.M.T., to practice as a massage therapist in the State of

Florida will be promptly instituted and acted upon in compliance with

Sections 120.569 and 120.60(6), Florida Statutes (2012).

In Re:

DONE and ORDERED this 20“

PREPARED BY:

Martin M. Randall Assistant General Counsel Florida Bar No. 0659940 DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65

Tallahassee, Florida 32399-3265 (P) 850-245-4640 (F) 850-245—4662

(E) [email protected]

-10-

Emergency Suspension of the License of Yuexia Wang, L.M.T. License No.: MA 64258 Case No.: 2012-13868

clay «W, 2012.

. Armstrong, MD Su eon General and Secretary of Health


NOTICE OF RIGHT TO JUDICIAL REVIEW

Pursuant to Sections 120.60(6) and 120.68, Florida Statutes, this

Order is judicially reviewable. Review proceedings are governed by the

Florida Rules of Appellate Procedure. Review proceedings are commenced

by filing a Petition for Review, in accordance with Florida Rule of Appellate

Procedure 9.100, with the District Court of Appeal, accompanied by a filing

fee prescribed by law, and a copy of the Petition with the Agency Clerk of

the Department within 30 days of the date this Order is filed.

-11-


DEPUTY CLERK CLERK Angel Sanders

STATE OF FLORIDA DATE NOV 0 1 2012


DEPARTMENT OF HEALTH, Petitioner,

v. DOH se No. 2-

YUEXIA WANG, Respondent.

VOLUNTAR E N UISHMENT F LICENSE

Respondent YUEXIA WANG, L.M.T., License No. MA 64258, hereby

voluntarily relinquishes Respondent's license to practice Massage in theState'of


1. Respondent's purpose in executing this Voluntary RelinquishMert is



Board) of this Voluntary Relinquishment shall be construed as disciplinary

action against Respondent's license pursuant to Section 456.07241n Florida

Statutes,

2. Respondent agrees to voluntarily cease pra massage

therapy immediately upon executing this Voluntary Rgilnquishmein

Respondent further agrees to refrain from the practice of

POO/ZOO@

MI 69 OL 6102/04/00


DEPUTY CLERK CLERK Angel Sanders

STATE OF FLORIDA ”ATE NOV 01 2012



Petitioner,

v. DOH Case No. 201243868‘

YUEXIA WANG, Respondent.

] VOLUNTARY RELINOUISHMENT 0F UCENSE

Respondent YUEXIA WANG, L. M T, License No. MA 64258, hereby

voluntarily relinquishes Respondent’s license to practice Massage in'mé‘Stateof


1. Respondent’s purpose In executing this Voluntary Relinquishmmt is



Board) of this Voluntary Relinquishment shall be construed as disclplinary

action against Respondent’s license pursuant to Section 456.0?251Xf), Florida if? ,

Statutes.

2. Respondent agrees to voluntarily cease pracflchg massage

therapy immediately upon executing this Voluntary Rellnqulstmt.

Respondent further agrees to refrain from the practice of 4;: 3:7,

coo/zoom xvs 85-01 6102/90/90

until such time as this Voluntary Relinquishment is presenttitifto, tWillOtird

and the Board issues a written final order in,this matter.

3. In order to expedite consideration and resolution ofrthis. salon- by

the Board in a public meeting, Respondent, being full‘radvised o the

consequences of so doing, hereby waives the statutOryt privilege of

confidentiality of Section 456.073(10), Florida Statutes, arid waives a

determination of probable cause, by the Probable Cause 1::Panelv;Or ithle

Department when appropriate, pursuant to Section 45003(4) ? I Florida

Statutes, regarding the complaint, the investigative report ofrtheDepartinent

of Health, and all other information obtained pursuant to the tlepartments

investigation in the above-styled action. By signing this waiver., Respondent

understands that the record and complaint become public record and remain

public record and that information is immediately accessible to the public:*

Section 456.073(10) Florida Statutes.

4. Upon the Board's acceptance of this Voluntary Reli

Respondent agrees to waive all rights to seek Judicial review of,

challenge or contest the validity of, this Voluntary Relinquishment

Final Order of the Board incorporating this Voluntary Relinquish

DOH v. YUEXIA WANG, LMT, Case No. 2012-13868

pooicoo

,z‘ é,‘, >‘»‘ a

unti! such time as this Voluntary Relin’quishment is presentédittdr-thémoam~

and the Board issues a written final order in«this matter. = ”‘31~

3. In order to expedite consideration and resolutionvofithis action by

the Board in a public meeting, Respondent, being fuily‘-Indviseds tbf‘utheE

consequences of so doing, hereby waives the stat pflvllegia’.niof

confidentiality of Section 456.073(10), Florida Statutes, ahd walyes a L

determination of probable cause,“ by the Probable Causefiifibnelgdbn'wme:

Department when appropriate, {pursuant-Io Section 456;07I3(4);itnida

Statutes, regarding the compIaint, the investigative report ofrmexDepdrfinent

of Health, and all other information obtained pursuant tothefiDEpamnent’s.

investigation in the above~styied action. By signing this waiVer, Respondent ‘

understands that the record and complaint become pubiic record and remain

public record and that information is immediately accessible to the public}

Section 456.073(10) Florida Statutes. .

4. Upon the Board's acceptance of mis Voluntary

Respondent agrees to waive all rights to seek judficlal review

challenge or contest the validity of, this Voluntary Rellnq c

Final Order of the Board incorporating this Voluntary Relinq

DOH V‘ YUEXIA WANG, LMT, Case No. 2012—13868

woo/cool

rd.

5. Petitioner and Respondent hereby agree that upon the rd's

acceptance of this Voluntary Relinquishment, each party shall] eaf: Its own "

attorney's fees and costs related to the prosecution or defense of this matter:

6. Respondent authorizes the Board to review and examine all

investigative file materials concerning Respondent in connection with the

Board's consideration of this Voluntary Relinquishment. Respondent .cirees!

that consideration of this Voluntary Relinquishment and other related materials ,

by the Board shall not prejudice or preclude the Board, or any-of;ics Terri*

from further participation, consideration, or resolution of these ;.proceedings if

the terms of this Voluntary Relinquishment are not accepted by

DATED this 15 4141 day of

YUIXIA WANG, 04:011L.

STATE OF -Raiff* N neu ORK-COUNTY OF: 0__U(E -Ni,

Before me, personally appeared V3 dror

identity is known to me by

and who, under oath, acknowledges that his/her signature

Sworn to and subscribed before me this L.51Clay of

NOTARY PUBLIC My Commission Expires:

DOH v, YIJEXIA WANG, LMT, Case No. 2012-13868

GIACCHINO J. RUSSO Notary Public, State of Nos Volt

No. 02RU4806109 (Neared in Westchester County

Commission Expires January 31,2015

voortoovi 0 ►,0/00

5. Petitioner and Rapondent hereby agree that upon :theséoardis‘

acceptance of this Voluntary Relinquishment, each party sha‘lh‘b‘e’au It; own

attorney's fees and costs related to the prosecution Or deferise of this matter; i

E

6. Respondent authorizes the Bogrd to review and examine aflf‘

investigative file materials concerning Respondent in connection With the

Board's consideration of this Voluntary Relinquishment. Rspondentéigreas

that consideration of this Votuntary Relinquishment and other felgted mitefiats

by the Board shall not prejudice or preclude the Boardflpr ariyivvoféigs ,mgmggfif

from further participation, consideration, or resotution. of these gpmmdings‘if

the terms of this Voluntary Relinquishment are not acCepted by th‘e Board. 'I' ‘ ‘

DATED this [5 4h day of OQ‘OW .; 2:012.

Yugfi WANG, Lg. . ,

STATE OFW Mam/012K coumv OF: Q .1 4 Egg 5

Before me, personally appeared . . . NVS dn‘V‘ Identity IS known to me by #1. )y-

and who, under oath, acknowledges that his/her 5!n Sworn to and subscribed before me this [Swoday of ‘

NOTARY PUBLIC

GIACCHINO J. RUM Nohry Public. sun- 0! NuM

No. DIRUMWS Ouatiflld in Watch-1n! County

Comb-Ion Expires Jammy 31, 2015 DOH v. YUEHA WANG, LMT. Case No. 2012-13868


voo/vool

1.1.,00.004.114.1

LAW OFFICE OF GIACCHINO RU S 0 ASSOCIATES, P. C 5116 7th Avenue Brooklyn, NY 11220 (T) 718 851-2582 (F) 718 851-2583

(FAX COVERSHEET From: Beth M. Moretti To: Martin Randall

Fax: (850) — 245 — 4662 Pages:

4 Pages (including cover

. Phone:

Re:

(850)-245-4640 (x. 81671_ Wang, Yuexia Case #: 13868

bate: October 31, 2012

Hi Martin,

Here is the signed and notarized VRL. The original will follow by mai[

Thank you,

GIACCHINO J, RUSSO, ESQ. • 5116 Avenue • Brooklyn. NY 11220 • PH: ,„7 8) 85

LAW OFFICE OF GIACCHINO RUSSO 8t ASSOCIATES, P. C.‘

S 116 7m Avenue Brooklyn. NY 11220 (n 718 851-2582 (F) 718 851-2583f

FAX COVERSHEET 3

To: Marlin Randall ‘ Fret—n: mEgth M. Moretfi _ $ ‘

j ‘

Fax: (850) — 245 — 4862 Pages: 4 Pages (including cov'pr) '

M _

(350)—245-1640 ""

‘

"W ‘

!

Phon:~ (X. 8167) Date. Of'hober 31. 2012

,... ‘ Wang, Yuexia

_ [Ra Case #: 13868 # cc‘

_'

Hi Martin,

Here is the signed and notarized VRL. The origlnal wlll follow by mail;

Thank you‘

vac/loo-



PETITIONER,

V. CASE NO. 2012-13868

Yuexia Wang, L.M.T.,

RESPONDENT.




Board of Massage Therapy against the Respondent, Yuexia Wang, L.M.T.,

and in support thereof alleges:

1. Petitioner is the state agency charged with regulating the

practice of massage therapy pursuant to Section 20.43, Florida Statutes

(2012), and Chapters 456 and 480, Florida Statutes (2012).

2. At all times material to this Complaint, Respondent was

licensed as a massage therapist in the State of Florida, having been issued

license number MA 64258.

3. Respondent's address of record is 43-40 Union Street,

Apartment 1K, Flushing, New York 11355.



PETITIONER,

v. CASE NO. 2012-13868

Yuexia Wang, L.M.T.,

RESPONDENT./




Board of Massage Therapy against the Respondent, Yuexia Wang, L.M.T.,

and in support thereof alleges:

1. Petitioner is the state agency charged with regulating the

practice of massage therapy pursuant to Section 20.43, Florida Statutes

(2012), and Chapters 456 and 480, Florida Statutes (2012).

2. At all times material to this Complaint, Respondent was

licensed as a massage therapist in the State of Florida, having been issued

license number MA 64258.

3. Respondent’s address of record is 43-40 Union Street,

Apartment 1K, Flushing, New York 11355.

4. On or about June 6, 2011, Respondent submitted a State of

Florida Application for Licensure as a massage therapist ("Application") to

the Florida Department of Health Board of Massage Therapy ("Florida

Board").

5. On her Application for Licensure, Respondent indicated that she


for the application, however, shows that Respondent received her massage


Pennsylvania.

6. The Professional School of Massage is not a Florida Board

approved school.

7. Respondent's Application further reveals that Respondent did



order to qualify for licensure as a massage therapist in the State of Florida




Page 2 of 8

4. On or about June 6, 2011, Respondent submitted a State of

Florida Application for Licensure as a massage therapist (“Application”) to

the Florida Department of Health Board of Massage Therapy (“Florida

Board").

5. On her Application for Licensure, Respondent indicated that she


for the application, however, shows that Respondent received her massage


Pennsylvania.

6. The Professional School of Massage is not a Florida Board

approved school.

7. Respondent’s Application further reveals that Respondent did



order to qualify for licensure as a massage therapist in the State of Florida




Page 2 of 8

9. Submitted to the Florida Board following Respondent's

Application was a transcript from Florida College of Natural Health

("FCNH").

10. The FCNH transcript represents that Respondent earned 500

credit hours in the FCNH Therapeutic Massage Training Program (Transfer

of Licensure).

11. The FCNH transcript indicates that Respondent started the

program on June 27. 2011, and completed the program on July 8, 2011.

12. Respondent also submitted, following her Application, a FCNH

Certificate of Completion of 35 hours of Therapeutic Massage Training

Program (Transfer of Licensure) dated July 8, 2011.

13. Also submitted following Respondent's Application for Licensure

was a Florida College of Natural Health Certificate of Completion of two

hours of Prevention of Medical Errors dated July 1, 2011.

14. On or about July 19, 2012, the Vice President of Compliance

and Institutional Effectiveness for FCNH ("V.P.") certified that the FCNH

transcript Respondent submitted with her Application is fraudulent.

15. On or about July 19, 2012, the V.P. also certified that

Respondent did not complete the courses identified in the certificates

Respondent submitted with her Application.

Page 3 of 8

9. Submitted to the Florida Board following Respondent’s

Application was a transcript from Florida College of Natural Health

(“FCNH").

10. The FCNH transcript represents that Respondent earned 500

credit hours in the FCNH Therapeutic Massage Training Program (Transfer

of Licensure).

11. The FCNH transcript indicates that Respondent started the

program on June 27. 2011, and completed the program on July 8, 2011.

12. Respondent also submitted, following her Application, a FCNH

Certificate of Completion of 35 hours of Therapeutic Massage Training

Program (Transfer of Licensure) dated July 8, 2011.

13. Also submitted following Respondent’s Application for Licensure

was a Florida College of Natural Health Certificate of Completion of two

hours of Prevention of Medical Errors dated July 1, 2011.

14. On or about July 19, 2012, the Vice President of Compliance

and Institutional Effectiveness for FCNH (“V.P.”) certified that the FCNH

transcript Respondent submitted with her Application is fraudulent.

15. On or about July 19, 2012, the VP. also certified that

Respondent did not complete the courses identified in the certificates

Respondent submitted with her Application.

Page 3 of 8


completion from, a Florida Board approved school, as required by Section

480.041(1)(b), Florida Statutes (2011), Respondent is not qualified to be

licensed, or to practice, as a massage therapist in the State of Florida.

COUNT ONE

17. Petitioner realleges and incorporates by reference the

allegations in paragraphs 1 through 16 as if fully set forth herein.


massage therapist to discipline for violating any provision of Chapter 480 or

456, Florida Statutes, or any rules adopted pursuant thereto.


massage therapist to discipline for attempting to obtain, obtaining, or

renewing a license to practice a profession by bribery, by fraudulent

misrepresentation, or through an error of the department or the board.

20. Based on the foregoing, Respondent has violated Section

480.046(1)(o), Florida Statutes (2011), by obtaining her license to practice

massage therapy in the State of Florida through error of the Department of

Health or through fraudulent misrepresentation by submitting a fraudulent

transcript and fraudulent Certificates of Completion with her Application, in

violation of Section 456.072(1)(h), Florida Statutes (2010-2011).

Page 4 of 8


completion from, a Florida Board approved school, as required by Section

480.041(1)(b), Florida Statutes (2011), Respondent is not qualified to be

licensed, or to practice, as a massage therapist in the State of Florida.

COUNT ONE







massage therapist to discipline for attempting to obtain, obtaining, or

renewing a license to practice a profession by bribery, by fraudulent

misrepresentation, or through an error of the department or the board.


480.046(1)(o), Florida Statutes (2011), by obtaining her license to practice

massage therapy in the State of Florida through error of the Department of

Health or through fraudulent misrepresentation by submitting a fraudulent


violation of Section 456.072(1)(h), Florida Statutes (2010—2011).

Page 4 of 8

COUNT TWO







massage therapist to discipline for failing to comply with the requirements

for profiling and credentialing, including, but not limited to, failing to

provide initial information, failing to timely provide updated information, or

making misleading, untrue, deceptive, or fraudulent representations on a

profile, credentialing, or initial or renewal licensure application.


480.046(1)(o), Florida Statutes (2011), by for failing to comply with the

requirements for profiling and credentialing by submitting a fraudulent


violation of Section 456.072(1)(w), Florida Statutes (2011).

Page 5 of 8

COUNT TWO







massage therapist to discipline for failing to comply with the requirements

for profiling and credentialing, including, but not limited to, failing to

provide initial information, failing to timely provide updated information, or

making misleading, untrue, deceptive, or fraudulent representations on a

profile, credentialing, or initial or renewal licensure application.


480.046(1)(o), Florida Statutes (2011), by for failing to comply with the

requirements for profiling and credentialing by submitting a fraudulent


violation of Section 456.072(1)(w), Florida Statutes (2011).

Page 5 of 8

COUNT THREE




licensee to discipline for violating any provision of Chapter 480 or Chapter

456, or any rules adopted pursuant thereto.


order to qualify for licensure as a massage therapist in the State of Florida,

a person must complete a course of study at a Florida Board-approved

massage school or complete an apprenticeship program that meets the

standards adopted by the Florida Board.

28. Respondent is not qualified to hold a license as a massage

therapist because she failed to complete a course of study at a Florida

Board-approved massage school and failed to complete an apprenticeship

program that meets the standards adopted by the Florida Board.


480.046(1)(o), Florida Statutes (2011), by obtaining a license as a

massage therapist without completing a course of study at a Florida Board-

approved massage school or an apprenticeship program that meets the

Page 6 of 8

COUNT TH REE




licensee to discipline for violating any provision of Chapter 480 or Chapter

456, or any rules adopted pursuant thereto.


order to qualify for licensure as a massage therapist in the State of Florida,

a person must complete a course of study at a Florida Board-approved

massage school or complete an apprenticeship program that meets the

standards adopted by the Florida Board.

28. Respondent is not qualified to hold a license as a massage

therapist because she failed to complete a course of study at a Florida

Board-approved massage school and failed to complete an apprenticeship

program that meets the standards adopted by the Florida Board.


480.046(1)(o), Florida Statutes (2011), by obtaining a license as a

massage therapist without completing a course of study at a Florida Board-

approved massage school or an apprenticeship program that meets the

Page 6 of 8

standards adopted by the Florida Board, in violation of Section

480.041(1)(b), Florida Statutes (2011).


Massage Therapy enter an order imposing one or more of the following

penalties: permanent revocation or suspension of Respondent's license,



and/or any other relief that the Board of Massage Therapy deems

appropriate.

SIGNED this 7lA day of (-/77_,61vir , 2012.

John H. Armstrong, MD State Surgeon Gen a rtd , cretary of Health /e

Martin M. Randall Assistant General Counsel Florida Bar No. 0659940 DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 (P) 850-245-4640 (F) 850-245-4662 (E) [email protected]

PCP Date: October 15, 2012 PCP Members: Harrison and Nixon


DEPUTY CLERK

CLERK Angela Barton DATE 10/17/2012

/7/

Page 7 of 8

standards adopted by the Florida Board, in violation of Section

480.041(1)(b), Florida Statutes (2011).


Massage Therapy enter an order imposing one or more of the following

penalties: permanent revocation or suspension of Respondent’s license,



and/or any other relief that the Board of Massage Therapy deems

appropriate. . ‘

SIGNED this #74 day of (xi/.4112? , 2012.

John H. Armstrong, MD

State Surgeon Ger}eral 91d 1, cretary of Health

FngF HEALTH T/Ld%//% fl, DEPASEEE'PY CLERK /[ 4‘

CLERK Angela Baznon Martin M. Randall ”A“ WWW

Assistant General Counsel Florida Bar No. 0659940 DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65

Tallahassee, Florida 32399-3265

(P) 850-245-4640 (F) 850-245-4662

(E) [email protected]

PCP Date: October 15, 2012 PCP Members: Harrison and Nixon

Page 7 of 8

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses, and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested.


Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on Respondent in addition to any other discipline imposed.

Page 8 of 8

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses, and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested.


Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on Respondent in addition to any other discipline imposed.

Page 8 of 8

FLORIDA |

Board of Massage Therapy APPLICANT WITH FOREIGN EDUCATION

WANDERLEY SOBRINHO, HELIO OLIVEIRA

DATE OF BIRTH: FILE NUMBER: 8799’] COMPLETION DATE: 08/11/2016

Education History School follows guidelines of GCMT for course materials/content. Licensing agency for schools does not exist in Great Britain. Applicant completed ITEC qualification, which standardizes some components of vocational training.



Rick Scott Governor






August 12, 2016 File:87991





HEALTH WWMWY Vision: Tobe the Healthist State in the Malian


August 12, 2016 File:87991








Sincerely,

,/ _

’ L4,]

’ WIZU/y/(VI

'

/ a





P H A B

of 5Date Created: Apr 19 2016 6:33PM




Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: MR. HELIO OLIVEIRA WANDERLEY SOBRINHODate of Birth: 12/09/1966Place of Birth: RECIFE, BRAZILEmail Address: [email protected]

Basic Data

Mailing Address1038 1038 25TH AVENUE NORTH, APT E ST. PETERSBURG, FL 33704

Physical Location or Address of Employment1038 1038 25TH AVENUE NORTH, APT E ST. PETERSBURG, FL 33704


Equal Opportunity DataGender: MALERace: WHITE

Education History

School Name: OTHERSchool Name: OXFORD SCHOOL OF

MASSAGESchool Address: OXFORD, UNITED

KINGDOMGraduation or Anticipated Graduation Date: 10/01/1996Total Number of Hours Completed: 500


Other Name HistoryName: HELIO OLIVEIRA WANDERLEYSOBRIN






Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. .a


Rick Scott Governor






Mailing Address 1038 1038 25TH AVENUE NORTH, APT E

ST. PETERSBURG, FL 33704

tsical Location or Address of Emplovment 1038 1038 25TH AVENUE NORTH, APT E

ST. PETERSBURG, FL 33704


RECIFE, BRAZIL

727—290—8227 727—288-1 235



LIVEIRA WANDERLEY SOBRINHO

HWANDERLEY.TR|GGER@GMA|L.COM

Gender: MALE Race: WHITE

Education Histom

School Name: OTHER School Name: School Name: OXFORD SCHOOL OF School Name:

MASSAGE School Address: School Address: OXFORD, UNITED Graduation or Anticipated

K'NGDOM Graduation Date: Graduation or Anticipated Total Number of Hours Graduation Date: 10/01/1996 Completed: Total Number of Hours Completed: 500

Other Name Histom Name:






HELIO OLIVEIRA WANDERLEYSOBRIN



Date Created: Apr 19 2016 6:33PM Page 1 of 5

I have NOT completed a two—hour course in the Prevention of Medical Errors.

HIV/AIDS Course


Electronic Fingerprinting The Florida Care Provider Background Screening Clearinghouse is unavailable at this time.

Acknowledgement Statement I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy, and right to challenge incorrect criminal history records and the "Privacy Statement" document from the Federal Bureau of Investigation. Your answer:

Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Your answer:

Discipline HistoLy

Have you ever been denied the right to take a massage therapy (or any other medical or Your answer: personal service) licensing examination in any state orjurisdiction’?




Are you now or have you ever been a defendant in a civil litigation in which the basis of YOUF answer: the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?



Date Created: Apr 19 2016 6:33PM

YES

NO

N0

N0

NO

NO

NO

NO

Page 2 of 5
















Email Notification


Date Created: Apr 19 2016 6:33PM Page 3 of5





Date Created: Apr 19 2016 6:33PM Page 5 of5

MEAN} - {RTFM/ED

JUN 21 2015

Continuing Eduaztionfur Licensed Massage Therapists

(“Tit/1.1171(1)”?

H5 (fa/7142311 Urine. Sahel/fit? Bz'ur/L FL 32937 /I1/()(il}<1'u/mr.com (305) 7 (134)2(18

Certificate of Achievement

Courses." (/bI‘ Florida licensure by endofsement)

> Florida Laws & Rules ([0 hours) CE Bro/(er Course #20-516004

> HIV/AIDS (4 hours) CE Broker Course #20—495467

5* Prevent-[0n qedical Errors (4 hour. ,CE Bra/(er Comtyc #20—4077

Name ofParI‘icz'panr: Hé

Applicant File # 87991

F laridq Ma {lg NCBEVB‘ CE

‘

This caurse‘wflk mee , criteria/0r the slate of F lon‘da, Board of Massage, Administrative Code, Chapter 6437»

g ducation. N W «M

Continuing Education/Or Licensed Massage Thai-(mists

(fI'ILf/J'I[1130111

3/.‘7 Cur/saw {)riw. .X'ulcllilc Brut-,1]. Fl. X2937 inlbmix-uu/lntmm .' (305) 793-0208

Certificate of Achievement

Courses: (for Florida Zicensure by endorsement)

r Florida Laws & Rules (10 hours) CE Bro/(Ur Course , 20-5} 6004

39‘ HIV/ AIDS (4 hours) CE Bi‘oker Course #2049546 7

> Prevention qf Medical Errors (

This coursewqc a; e critermfor the state of Florida, Board of Massage. Administrative Code. Chapter 6487- 28, 009 of Continumg Education. 9%.?“l


Rick Scott Governor





May 6, 2016 Mr. Helio Oliveira Wanderley Sobrinho 1038 1038 25th Avenue North, Apt E St. Petersburg, FL 33704


_____ We have not received proof of completion of a three (3) hour HIV/AIDS course as required by

Section 456.013(7), F. S. Course must be taken from a Florida Board approved school, Florida Board approved continuing education provider, or the American Red Cross. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

_____ We have not received your Livescan results. If you have already had your electronic fingerprinting (Livescan) completed, please allow 24-72 hours for receipt of your results. The Board of Massage Therapy cannot accept hard copy (paper) fingerprint cards. All applicants must have electronic fingerprinting completed by a Florida Department of Law Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.floridahealth.gov/licensing-and-regulation/background-screening/index.html Please use the electronic fingerprint form found in the application or on our website at: http://floridasmassagetherapy.gov/resources/

_____ We have not received proof of completion of a two (2) hour prevention of medical errors course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

_____ We have not received a passing score directly from the Federation of State Massage Therapy Boards (FSMTB). Please contact the FSMTB and have them release your score to our office. They may be reached at 1-866-962-3926 or at www.fsmtb.org.

_____ We may be able to accept your educational transcript from a foreign country, but your application file and materials will have to go before a meeting of the Board for an additional review. What you will need to gather are certified translations and evaluations of all of your educational credentials, including documentation that establishes that the massage therapy


Gwemor

“a" Wei” Hm‘hmwimegm‘ed ‘ , Celeste Philip, MD, MPH

stale, oomty&ommnfly efia‘ts.

H EALTH Interim Stale Slgeon General


May 6, 2016

Mr. Helio Oliveira Wanderley Sobrinho 1038 1038 25th Avenue North, Apt E St. Petersburg, FL 33704

File No. 87991

Dear Applicant:




All applicants must have electronic fingerprinting completed by a Florida Department of Law Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.f|oridahealth.gov/Iicensing-and- reguIation/background-screening/index.html

Please use the electronic fingerprint form found in the application or on our website at: http://f|oridasmassagetherapy.gov/resources/



We may be able to accept your educational transcript from a foreign country, but your application file and materials will have to go before a meeting of the Board for an additional review. What you will need to gather are certified translations and evaluations of all of your educational credentials, including documentation that establishes that the massage therapy



P H A B

program that you attended was approved by the proper authorities there (Board of Education, Board of Massage, government licensing authority, etc.). Once you have submitted those materials, we will place them with your application file and submit it to the Board for review at their next meeting.

_____ You have indicated that your massage therapy education was completed outside of Florida.

Please submit the following: Official transcript mailed directly from your massage therapy school. If the school has

closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript.

Please have your school complete the Breakdown of Hours worksheet and submit it to our office, outlining the courses that fulfill the requirements for licensure. The form is located in the Forms & Requests section on the following page: http://floridasmassagetherapy.gov/resources/.

Please submit proof of your massage therapy school's approval by the equivalent State licensing agency or State Department of Education in which it is located.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username wanderhe and password dRF2Qec4 to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,

Alexandra Alday Program Operations Admin

program that you attended was approved by the proper authorities there (Board of Education, Board of Massage, government licensing authority, etc.). Once you have submitted those materials, we will place them with your application file and submit it to the Board for review at their next meeting.

You have indicated that your massage therapy education was completed outside of Florida. Please submit the following: . Official transcript mailed directly from your massage therapy school. If the school has

closed, you must submit documentation from the custodian of records (normally the state Department of Education) attesting that they are unable to provide a copy of your transcript.

. Please have your school complete the Breakdown of Hours worksheet and submit it to our office, outlining the courses that fulfill the requirements for licensure. The form is located in the Forms & Requests section on the following page: http://f|oridasmassagetherapy.gov/resourcesl.

. Please submit proof of your massage therapy school's approval by the equivalent State licensing agency or State Department of Education in which it is located.


You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/m aservices/lo in.as Once there, select your profession and enter your usernamfito check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


Sincerely,

Alexandra Alday Program Operations Admin

FLOR A \

Board of Massage Therapy PETITION FOR VARIANCE OR WAIVER

Tiera Diana Baize DOB:— File No: 88264 Completed: — Incomplete, petition filed.

School approved by Indiana Workforce Development



Rick Scott Governor






August 18, 2016 File:88264

To: Tiera Diana Baize

5301 Reflections Club Dr. 205 Tampa, FL 33634

Date: September 14, 2016 Time: 9:00 am Type: Conference Call Meet Me Number: (888)-670-3525 Participation Code: 2597709961 Your participation is not required. However, all respondents are encouraged to participate in the conference call. If you do not participate, the Board may require your appearance at a regularly scheduled Board meeting. Should the Board require your appearance, you will be required to appear at one of the next two regularly scheduled meetings. This may further delay a decision on your licensure. Please call in by 8:00 AM to sign-in. Copies of the meeting agenda will not be provided at the meeting; if you would like a copy please go to the following web address: www.doh.state.fl.us/mqa/massage/ma_meeting.html. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner.

Sincerely,




Ham WWW Vision: Tobe the Healthist State in the Malian


August 18, 2016 File:88264

To: Tiera Diana Baize 5301 Reflections Club Dr. 205 Tampa, FL 33634







Sincerely,

«QM Samantha Jenkins Regulatory Specialist II




P H A B


Deputy Clerk CLERK ofmckai am.dah-4_

DATE JUL 1 8 2016 Petition For Waiver of Rule 480.041(1)(b)

To: Joint Administrative Procedures Committee Room 680, Pepper Building 111 W Madison St. Tallahassee, FL 32399-1400

From: Tiera Baize

5807 Accent Dr.

Indianapolis, IN 47221

[email protected]

812-381-1118

File No. 88264 86 :6

WV

8Z NIT

HOZ

CIJA

103

2:1

To Whom It May Concern:

I request to Petition to waive rule 480.041(1) (b) stating one has completed a course or study at a board-approved

massage school or has completed an apprenticeship program that meets the standards adopted by the board.

I am requesting for the Florida Board of Massage Therapy to accept a copy of my transcripts as I was unable to get

them directly from my school. The School I attended in Indiana, Associates of Integrative Health (AIH), closed in tate

2013.

AIH was formally located at 335 South College Avenue, Bloomington, Indiana. AIH was accredited and offered a 500

hour massage therapy program. AIH was granted status on September 5, 2003 by the Indiana Commission on

Proprietary Education (ICOPE), which is now defunct.

ICOPE responsibilities were transferred to the State Workforce Innovation Council, Office for Career and Technical

Schools. AIH stayed in good standing with this agency. AIH voluntarily closed and teach-out in late 2013. The teach-

out was completed as of January 1, 2014. Any individual wishing to become certified as a massage therapist in

Indiana must complete a program with 500 hours on supervised classroom and hands on instruction. Graduates

from AIH are eligible to sit for the certification exam in Indiana.

Since AIH closed I was unable to have them send official transcripts to the Florida Board of Massage. I went to many

departments to try and locate them. I started at the Department of Education. They then advised me to go to the

Commission for Higher education. Commission for Higher education directed me to Indiana Archives. Indiana

Archives did not have transcripts due to the school not closing properly. I then contacted Indiana Professional

Licensing Agency. They had a copy and sent it to me electronically. I then sent a copy to Indiana Archives. They then

sent a copy of my transcripts and Certification from my school with graduation date on it via Fax and USPS.

This waiver would serve the purpose of the underlying statue being that AIH was an accredited 500 hour school and

I sat for the National Certification Board for Therapeutic Massage and Bodywork exam and past. I was then licensed

in Indiana. I wish for this waiver to be permanent so I can practice as a licensed massage therapist in the state of

Florida.

Sincerely,

Tiera Diana (Jordan) Baize

File No. 88264

FILED DepamncntOfI-Iealth

Deputy Clerk CLERK awn; arm DATE JUL 18 2015

Petition For Waiver of Rule 480.041(1)(b)

To: Joint Administrative Proeedures Committee Room 680, Pepper Building

111 W Madison St. 11; M Tallahassee, FL 32399—1400 893 a

0;?- ‘” rr535 c... :0

From: Tiera Balze 93%;; E m 5807 Accent Dr. 5;?" g 2 Indianapolis, IN 47221 05'; 2

. . CD—I 3"" tIeradlanamacom In I m 812-381-1118 éfj 29 ‘3 File No. 88264 fig 8

To Whom It May Concern:

| request to Petition to waive rule 480.041(1) (b) stating one has completed a course or study at a board—approved

massage school or has completed an apprenticeship program that meets the standards adopted by the board.

I am requesting for the Florida Board of Massage Therapy to accept a copy of my transcripts as I was unable to get

them direcfly from my school. The School I attended in Indiana, Assocla‘es of Integrative Health (AIH), closed In late

2013.

AIH was formally located at 335 South College Avenue, Bloomlngton, Indiana. AIH was accredited and offered a 500

hour massage therapy program. AIH was granted status on September 5,2003 by the Indiana Commission on

Proprietary Education (ICOPE), which IS now defunct.

[COPE responsibilities were transferred to the State Workforce Innovation CounCII, Office for Career and Technical

Schools. AIH stayed in good standmg wlth this agency. AIH voluntarily closed and teach—out m late 2013. The teach-

out was completed as of January 1, 2014. Any indivldual wishing :0 become cemfled as a massage therapist in

Indiana must complete a program with 500 hours on supervised dassroom and hands on ins‘ruction. Graduates

from AIH are eligible to sit for the certification exam in Indiana.

Since AIH closed I was unable to have them send official transcripts to the Florida Board of Massage. I went to many

departments to try and locate them‘ I started at the Department of Educatlon. They then advised me to go to the

Commission for Higher education. Commission for Higher education directed me to Indiana Archives. Indiana

Archives did not have transcripts due to the school not closmg properly. I then contacted Indiana Professional

Licensing Agency. They had a copy and sent It to me electronically. I then sent a copy to Indiana Archives. They then

sent a copy of my transcripts and Certification from my school with graduation date on It via Fax and USPS.

This waiver would serve the purpose of the underlying statue being that AIH was an accredited 500 hour school and

I sat for the Natlonal Certification Board for Therapeutic Massage and Bodywork exam and past. I was then licensed

in lndiana. I wish for this waiver to be permanent so ! can practice as a licensed maSsage therapist in the state of

Florida.

Sincerely,

Tiera Diana (Jordan) Baize

File No. 88264

tH





Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST ENDORSEMENT APPLICATIONName: TIERA DIANA BAIZEDate of Birth: 10/30/1986Place of Birth: BLOOMINGTON, INEmail Address: [email protected]

Basic Data

Mailing Address5807 ACCENT DR INDIANAPOLIS, IN 46221

Physical Location or Address of Employment5807 ACCENT DR INDIANAPOLIS, IN 46221



Education History

School Name: INDIANA APPROVED PROGRAM

School Name: ASSOCIATES OF INTEGRATIVE HEALTH



Other Name HistoryName: TIERA DIANA JORDAN


License Number: MT21003694License Type: MASSAGE THERAPISTLicensure Date: 05/15/2010Date of Expiration: 05/15/2017Country: UNITED STATESState: INDIANAEndorsement State: YES

License Number:License Type:Licensure Date:Date of Expiration:Country:State:Endorsement State:



Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. firidz


Rick Scott Governor



Mailing Address 5807 ACCENT DR




MASSAGE THERAPIST INITIAL MASSAGE THERAPIST ENDORSEMENT APPLICATION TIERA DIANA BAIZE

BLOOMINGTON, IN

T|ERAD|ANA@GMA|L.COM

INDIANAPOLIS, IN 46221

tsical Location or Address of Emplovment 5807 ACCENT DR INDIANAPOLIS, IN 46221



812—381—1 118 812-384—6782

Gender: FEMALE Race: WHITE

Education Histom

School Name: INDIANA APPROVED School Name: PROGRAM School Name:

School Name: ASSOCIATES OF School Address:

School Address: Graduation or Anticipated

INTEGRATIVE HEALTH Graduation or Anticipated Graduation Date: Total Number of Hours

Graduation Date: 08/08/2008 Completed: Total Number of Hours Completed: 500

Other Name Histom Name: TIERA DIANA JORDAN


License Number: MT21003694 License Number: License Type: MASSAGE THERAPIST License Type: Licensure Date: 05/15/2010 Licensure Date: Date of Expiration: 05/15/2017 Date of Expiration: Country: UNITED STATES Country: State: INDIANA State: Endorsement State: YES Endorsement State:



Date Created: May 11 2016 1:57PM Page 1 of 5


Provider Number: 50—16951 Provider/School Name: ADVANCED MASSAGE TECHNIQUES, INC Course Name/Title: 20—314907 Date Completed: 05/09/2016

Prevention of Medical Errors I have completed the Prevention of Medical Errors education required by Florida Statutes, as defined by Rule 64B7—25.001(1)(f), F.A.C. Provider Number: 50—16951 Provider/School Name: ADVANCED MASSAGE TEXHNIQUES Course Name/Title: 20—266523 Date Completed: 03/23/2016

HIV/AIDS Course


Provider Number: 50—16951 Provider/School Name: ADVANCED MASSAGE TECHNIQUES Course Name/Title: 20—322089 Date Completed: 03/23/2016



Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense? Your answer: NO

Discipline Histom

Have you ever been denied the right to take a massage therapy (or any other medical or Your answer: N0 personal service) licensing examination in any state orjurisdiction?




Are you now or have you ever been a defendant in a civil litigation in which the basis of Your answer: No the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?

Is there currently pending against you (in any state orjurisdiction) a complaint against Your answer: No your professional conduct or competence?

In the last five years, have you been expelled, suspended from, or had disciplinary action Your answer: N0 taken against you by an educational institution other than your high school?

















Email Notification



aqsqffl STATE OF INDIANA Id'Pl’iullJ‘A' M‘Chaei R‘ Pen“ 432'€£K\r§n§§$ 5; 13'0a $0151?"

Plume: (.317) 232-2980 a: (Jr!) 233-4236

Official Proof of Licensure

ludianapalis. IN 46204

Digitally Certified Record

Personal Information V ,

Txéra Dikna’Baizé

580,7,‘AcoemDfive‘ ._ " ',IN4622_1_,

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This licensee has met ALL requiremems for Iicensure in the State of Indiana » including successfully passing all required exams.

For additional informaiion including questions regarding Disciplinary Action, contact the appropriale

Board or Commission at www.mgov/pla/boards hlm

Digitally Certified on: Fri May 18 11:21:05 AM EDT 2016

QMIEDST/JTES ’7’" POSTAL SERVICE 3,»

Electronic Postmark

STATE OF INDIANA ' Indium mtsxiona! ”conning Agency Ailchael R Pence

401 W. W'uhinglon St. Room “‘01"! lndiunpolb. IN 462.04 Phone: {317) 232-2980 Fax: (3”) 233-42“

RECEIVED (

MAY 1 8 2015

Digitally Certified Proof of Licensure

RE: Tiera Diana Baize

I, Deborah J. Frye, Executive Director of the Indiana

Professional Licensing Agency and custodian of the records

therein, hereby certify that the attached is the digitally

certified proof of licensure, as requested, and as it appears

in the files of the Indiana Professional Licensing Agency on

the date/time cenified.

This digital certification follows the requirements of Indiana's

Electronic Digital Signature Act (Indiana Code 5—24-1-1 et

seq.) and rules developed by the Indiana State Board of

Accounts, 20 IAC 3-1 et seq. to establish a valid digital electronic signature

If you have the need to verify the authenticity of the digital

cenification as of the date and time stamp below, 90 to mlpszl/secure ingov/apps/pla/verify.him and use our free web service to "Verify an Electronic Certified Record". Simply browse to the location you saved the secure pdf document sent to you and upload to validate.

Maw» Deborah J. Frye, Executive Director Fri May 13 11:21 :05 AM EDT 2016

p- uwrgo STATES. POSTAL SERVICE x

Electronic Postmark

FLORIDA \

Board of Massage Therapy PETITION FOR VARIANCE OR WAIVER / APPLICANT WITH OUT OF STATE EDUCATION

KUMAR, JESSICA DATE OF BIRTH: _ FILE NUMBER: 86607 COMPLETION DATE: WWW

Petition Filed 07/18/2016



Rick Scott Governor






August 18, 2016 File:86607

To: Jessica Nicole Kumar

560 S Line Rd Lecanto, FL 34461



Rick Scott Mussmn:




August 18, 2016 File:86607

To: Jessica Nicole Kumar 560 8 Line Rd Lecanto, FL 34461








Sincerely,

J r

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P


Deputy Clerk CLERK

JULl crasceichi_

DATE L 1 8 2016

Petition for variance from Rule 64B7-32.003

Petitioner: Jessica Kumar 560 S Line Rd. Lecanto, Fl 34461 [email protected] 352-201-2005 File # 86607

Applicable rule: 6 41 7- 3 2.00 3 (b) Offer a course of study that Includes, at a minimum, the 500 classroom hours listed below, completed at the

rate of no more than 6 classroom hours per day and no more than 30 classroom hours per calendar week: Course of Study Classroom Hours

Anatomy and Physiology 150

Citation to the statute the rule is implementing: https://www.flrules.ordgateway/ruleno.asp?id=64B7-32.003&Section=0

Type of action requested: Variance from

Specific Facts:

I have completed the requirements to satisfy the Anatomy and Physiology at two separate Educational institutions.

Windward Therapeutic Massage Center (Hawaii): 50 hrs completed Brigham Young University-Hawaii: over 150 hrs completed

Please refer to the transcripts in the file. I would like to highlight the courses taken at Brigham Young University-Hawaii which satisfy this requirement.

RECEIVED

JUL 1 5 2016

BY•

CZ

:DI W

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ill

5U

1) BIOL 260 2) BIOL 260L 3) BIOL 261 4) BIOL 261L 5) EXS 280 6) EXS 260L 7) EXS 341

2 credits = 2 hrs a week x 15 weeks = 30 classroom hours 1 credit =1 hr of cadaver lab a week x 15 weeks = 15 classroom lab hours 3 credits = 3 hrs a week x 15 weeks = 45 classroom hours 1 credit =1 hr of lab per week x 15 weeks = 15 classroom lab hours 2 credits = 2 hrs a week x 15 weeks = 30 classroom hrs 1 credit =1 hr of lab a week x 15 weeks = 15 classroom lab hours 3 credits = 3 hr a week x 15 weeks = 45 classroom hours

Reason why: I graduated with a Bachelor's in Exercise and Sports Science in April 2014. In reviewing my transcript from Brigham Young University- Hawaii you will see that I have completed several courses relating to the Human body. Many of these courses require an understanding of anatomy, physiology and kinesiology to complete successfully. I also completed additional schooling at Windward Therapeutic Massage center in order to become a Licensed Massage

In 0

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FILED Dcpanment Of Health

CLERK Deputy Clerk

pm JU‘L""“1 83mm

Petition for variance from Rule 64B7-32.003 V

7:

Petitioner: Jessica Kumar 560 5 Line Rd.

Lecanto, Fl 34461

aicole89@fll._co_m 352-201-2005 File # 86607

RECEIVED

BY: €S=UIHV

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SHE

Applicable rule: (a q 3 7 - 3 2 . DO 3 (b) Offer a course of study that Includes, at a minimum, the 500 classroom hours listed below, completed at the

rate of no more than 6 classroom hours per day and no more than 30 classroom hours per calendar week:

Course ofStudy Classroom Hours

Anatomy and Physiology 150

Citation to the statute the rule ls implementing: https://www.flrules.org/gateway/ruleno.asp?id=64B7—32.003&Section=0

Type of action requested: Variance from

Specific Facts:

1 have completed the requirements to satisfy the Anatomy and Physiology at two separate

Educational institutions. Windward Therapeutic Massage Center (Hawaii): 50 hrs completed Brigham Young University-Hawaii: over 150 hrs completed

Please refer to the tmnscripts in the file. I would like to highlight the courses taken at Brigham

Young Universlty-Hawaii which Satisfy thls requirement.

1) BIOL 260 2 credits = 2 hrs a week x 15 weeks = 30 classroom hours

2) BIOL 260L 1 credit = 1 hr of cadaver lab a Week x 15 weeks = 15 classroom |ab~hours

3) BIOL 261 3 credlts = 3 hrs a week x 15 weeks = 45 classroom hours

4) BIOL 261L 1 credit = 1 hr oflab per week x 15 weeks = 15 classroom lab hours

5) EXS 260 2 credits = 2 hrs a week x 15 weeks = 30 classroom hrs

6) EXS 260L 1 credit = 1 hr of lab a week x 15 weeks = 15 classroom lab hours

7) EXS 341 3 credits = 3 hr a week x 15 weeks = 45 classroom hours

Reason why: I graduated with a Bachelor’s in Exercise and Sports Science in April 2014. In reviewing my transcript from Brigham Young University— Hawaii you will see that I have completed several

courses relatlng to the Human body. Many ofthese courses require an understanding of anatomy, physiology and klneskology to complete suocessfufly. I also completed additional

schoollng at Windward Therapeutic Massage center in order to become a Licensed Massage

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Therapist in the State of Hawaii. Upon moving to Florida I completed the necessary requirements (Florida Laws and Rules, Prevention of Medical Errors, HIV/AIDS education) online and passed the Mblex. I have completed all requirements by the Florida Board of Massage Therapy and would like both transcripts considered for my licensing.

Permanent or temporary: This requested Variance is Permanent

Therapist in the State of Hawaii. Upon moving to Florida I compIeted the necessary

requirements (Florida Laws and Rules, Prevention of Medical Errors, HIV/AIDS education) online and passed the Mblex. l have completed all requirements by the Florida Board of Massage

Therapy and would like both transcripts considered for my licensing.

Permanent or temporary: This requested Variance is Permanent

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Rick Scott Governor




Profession: MASSAGE THERAPISTApplication Type: INITIAL MASSAGE THERAPIST EXAM APPLICATIONName: JESSICA NICOLE KUMARDate of Birth: 10/12/1989Place of Birth: LAKELAND, FLORIDAEmail Address: [email protected]

Basic Data

Mailing Address560 S LINE RD LECANTO, FL 34461

Physical Location or Address of Employment560 S LINE RD LECANTO, FL 34461



Education History

School Name: HAWAII APPROVED PROGRAM

School Name: WINDWARD THERAPEUTIC MASSAGE CENTER



Other Name HistoryName: JESSICA NICOLE FULFORD


License Number: 14290License Type: MASSAGE THERAPISTLicensure Date: 03/19/2015Date of Expiration: 06/30/2016Country: UNITED STATESState: HAWAII

License Number:License Type:Licensure Date:Date of Expiration:Country:State:




Mission: To protect, promote, & improve the health of all people in Florida through integrated state, county & community efforts. 3


Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary


Mailing Address 560 8 LINE RD LECANTO, FL 34461





OLE KUMAR

LAKELAND, FLORIDA [email protected]

tsical Location or Address of Emplovment 560 8 LINE RD LECANTO, FL 34461



352—201—2005

Gender: FEMALE Race: WHITE

Education Histom

School Name: HAWAII APPROVED School Name: PROGRAM School Name:

School Name: WINDWARD THERAPEUTIC School Address: MASSAGE CENTER Graduation or Anticipated

SChOOI Address: Graduation Date: Graduation or Anticipated Total Number of Hours Graduation Date: 02/24/2015 Completed: Total Number of Hours Completed: 600

Other Name Histom Name: JESSICA NICOLE FULFORD



14290 MASSAGE THERAPIST 03/19/2015 06/30/2016 UNITED STATES HAWAII







Date Created: Dec 4 2015 4:18PM Page 1 of 5


I have NOT completed a two—hour course in the Prevention of Medical Errors.

HIV/AIDS Course



Acknowledgement Statement

I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy, and right to challenge incorrect criminal history records and the "Privacy Statement" document from the Federal Bureau of Investigation. Your answer:

Criminal Histom

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in anyjurisdiction other than a minor traffic offense? Your answer:

Discipline Histom

Have you ever been denied the right to take a massage therapy (or any other medical or Your answer: personal service) licensing examination in any state orjurisdiction?




Are you now or have you ever been a defendant in a civil litigation in which the basis of Your answer: the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct?



Date Created: Dec 4 2015 4:18PM

YES

NO

N0

NO

NO

NO

N0

NO

Page 2 of 5

















Email Notification


Date Created: Dec 4 2015 4:18PM Page 3 of5





Date Created: Dec 4 2015 4:18PM Page 5 of5

KICK 850“ ”'3‘”: w Governor To proteCt. promote, 8; improve the health of all people In Florida through integrated

Fl 'rl.da John H strong MD FIGS 0 - Al I“ l , ‘. sate, county & community effortS-

sme Surgeon General 8: Secretary EA J H

Vislonflo be the Healthies! State in the Nation 2 W

Florida Department of Health Ten Hour Florida Laws 8. Rules Course

Name: JESSICA NICOLE KUMAR Profession: 1401 Transaction Code: 1021 File Number: 86607

You must provide a copy of your completion certificate of an approved 10 hour Florida Laws and Rules course to the Board Office prior to the issuance of your license. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877434—6323 or www.CEBroker.com.

Please mail or fax this information, along with this cover sheet to:

Florida Board of Massage Therapy 4052 Bald Cypress Way, Bin C-06 Tallahassee, FL 32399-3256

FAX: (850) 412 - 2681

RE EEIVED‘ DEC 14 2015

BY: .. _~._

Current Date: 12/7/15

god'Ma of M

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Jessica Kum

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NA

has successfully completed the follow

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10 Hour F

lorida Massage Law

and Rules #2061490?

CE

Hours granted:

10 D

ate of Com

pletion: Decem

ber 4. 2015

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. Course Instructor

Advanced M

assage Techniques

7841 11‘h Avenue T

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info@advancedm

assagetechniq1ues.com

[877) 5 15-9971

NC

BT

MB

Approved P

rovider #451043‘09 F

lorida Board of M

assage Approved C

E P

rovider #5046951 S

ite: course completed onllne in hom

e study format.

“loam Misslon: W Governor To protect. promote, & improve the health ‘ _- of all peopie in Florida through Integrated ‘ 0.

~ state, county 8: community efforts, F Oflda M“ ”' Armstrong, "9’ F‘cs ‘ E

a I 11" State Surgeon General & Secretary

VisionzTo be the Healthiest State In the Nation

Florida Department of Health Three Hour HIV/AIDS Course

Name: JESSICA NICOLE KUMAR Profession: 1401 Transaction Code: 1021 File Number 86607

You must provide a copy of your completion certificate of an approved three hour HIV/AIDS Education course to the Board Office prior to the issuance of your license. Course must be taken from a Florida Board approved school, Florida Board approved continuing education provider, or the American Red Cross. For Board approved courses contact CE Broker at 1—877-434-6323 or www.CEBmker.com

Please mail or fax this information, along with this cover sheet to:

Florida Board of Massage Therapy 4052 Bald Cypress Way, Bin C-06 Tallahassee. FL 32399—3256

FAX: (850) 412 - 2681


§MW

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This is to certify

Jessica Kum

ar

NA

has successfuliy completed the follow

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HIV

IAID

S for M

assage and Bodyw

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ours) #20322089

CE

Hours w

anted: 3

Date of C

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DeG

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7841 11‘“ Avenue T

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Belle P

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info@advancedm

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[877) 515-9971

NC

BT

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ite: course completed online in hom

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Inca own "‘55'9"; W Governor To protect. promote. & improve the health ~ of all people in Florida through integratEd a .h

- stale, County&communityefforts, Florlda John H. Armstrong, III), FAcs

HEALTH State Surgeon General & Secretary


Florida Department of Health Prevention of Medical Errors Course

Name: JESSICA NICOLE KUMAR Profession: 1401 Transaction Code: 1021 File Number: 86607

You must provide a copy of your completion certificate of an approved two (2) hour Prevention of Medical Errors course to the Board Office prior to the issuance of your license. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

Please mail or fax this information. along with this cover sheet to:

Florida Board of Massage Therapy 4052 Bald Cypress Way, Bin C-06 Tallahassee. FL 32399-3256

FAX: (850) 412 - 2681


6021M» of W

WW

T

his is to certify

Jessica Kum

ar

NA

has successfully completed (he follow

ing course

Prevention of M

edical Errors for M

assage Professionais

#20-266523

CE

Hours slanted:

2 D

ate of Com

ma/non: D

ecember 7~

2015

73;; 2 WM

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1w 1. H

uttqulst, LMT

. Course Insttuctot

Advanced M

assage Techniques

7841 11‘h Avenue T

rail

Betle P

laine. IA 52208

info@advancedm

assagetechniques.com

(877] 515-9971

NC

B'I'M

B A

pproved Provider “51043-09

Florida B

oard of Massage A

pproved CE

Provider 350-16951

Site: course com

pleted online in home study form

at.

Professional & Vocational License Search Page 1 of 3

Mali W 9975663

Professional &Vocationa| Lice 1

sing Search Department of Commerce & Consumer Affairs

8 General Licensee

| License ID:

' MAT-14290

Actlvellnactlve:

ACTIVE

Status

CURRENT, VALID & IN GOOD STANDING

Expire Date:

6/30/2016

Legal License Name: Trade/Professlonal Name: Entlty: Original License Date:

JESSICA N KUMAR -- INDIVIDUAL 3/19/2015

Class Prefix: Special Privilege: Restriction: Educatlon Code:

Business Code Condixions & Limitatiuns: Business Address:

License information on this site reflects informalion in the Professional and Vocational Licensing Division as ofjanuary 7, 2016;

however, applications and forms are subject (0 standard processing time, and the information here does not reflect pending changes which are being reviewed. The site is updated daily, Monday through Friday, except holidays,

The State of Hawaii makes no guarantees as to the accuracy of the informaxion accessed, the timeliness of the delivery of transactions, delivery to the correct party, preservation of the privacy and security of users and makes no warranties, including warranty 0! merchantability and fitness for a particular purpose‘ The DCCA/PVL web site receives the DCCA/PVL licensee Information direcfly from the DCCA/PVL licensee database‘ The DCCA/PVL web siKe is considered a primary source for DCCA/PVL

licensee informanon — it is the same licensee information (he DCCA/PVL provides through other means and is true and correct to the best of our knowledge. User is advised that if the information obtained herein is to be reasonably relied upon, user should confirm the accuracy of such information with the provider (hereof‘

https://pv].ehawaii.gov/pvlsearch/info/MAT—14290-0 1/7/2016

Professional & Vocational License Search

35 Employees List

EMPLOYEES

Poslllan : Posltlon Status : Employee Name 3

No data available In table

I Showing 0 to 0 of 0 entries L _ -,s

E Employers List

EMPLOYERS

Posltlon : Employer Name = m ID ¢

No data available in table

Showing 0 to 0 of 0 entries

fl“ Insurance / Bond

Insurance / Bond

lnsuranc: Type e Efrem" : Tenn Dale :

No data available in table

Showing 0 to 0 of 0 entries

; * License Class

License Classes

Class Code 9 class Type c Effective e

No data available in xable

https://pvl.ehawaii.gov/pvlsearch/info/MAT-14290-0

LI: ID 9

Cancel Dare é

Page 2 of 3

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1/7/2016

Professional & Vocational License Search Page 3 of 3

Showing 0 to 0 of 0 entries k _ . V _ . .

Click here to enter search criteria for orior complaints historv ->

(http://web.dcca.hawaii.gov/RICO)

For prior complaints and disciplinary history, contact licensing and business

information center at (808) 587 - 3295.

‘I—E‘) Back to Resultsfily Q New Search ()pvlsearch)

Professional & Vocational Licensing

Department of Commerce & Consumer Affairs

Accessibility (http://portaLehawaii.gov/accessibilityhtml) Contact (httpszllportaLehawaii.gov/page/about-us/) Feedback (http://porta|.ehawaiLgov/feedback.html?app|icationId=5) Privacy Policy

(http://porta|.ehawaii.gov/privacy—policy.htmI) Terms of Use

(http://porta|.ehawaii.gov/terms-of—use.html)

Copyright © 2013

State of Hawai'i. All rights reserved.

Powered by HI; (Hawaii nlnfprmgtlipr] CWSWFWW) (http://hic.ehawaii.gov)

https://pv1.ehawaii.gov/pvlsearch/info/MAT-14290-0 1/7/2016

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a;g

My name is Sabrina Ahn and I am the director of New Wave Myotherapy Academy. Attached is a copy of the private career school approval certificate of approval for the New Wave Myotherapy Academy for the period ofJan 1,2014 through December 31, 2014.

If you have any questions, please contact me at 201—592-1008 or via email at [email protected].


Rick Scott Governor








January 8, 2016 Jessica Nicole Kumar 560 S Line Rd Lecanto, FL 34461


We have received an official transcript mailed directly from a massage therapy school, however it is not on counterfeit-proof paper as required by Rule Title 64B7-32.002(2)(a), FAC. Please have your school send a transcript printed on counterfeit-proof paper or you may file a petition for variance or waiver of the rule requirement. Instructions can be found: http://www.floridahealth.gov/licensing-and-regulation/declaratory/variance.html We are unable to verify the approval of your massage therapy school. Please have your massage therapy school submit proof of approval by the equivalent State licensing agency or State Department of Education in which it is located. Our office has received your transcript, but cannot verify that each category of required hours has been satisfied. Please have your school complete the enclosed form and submit it to our office, outlining the courses that fulfill the category requirements for licensure.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username kumarjes and password 3!26712mK to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Rick Scott Mussmn.





January 8, 2016

Jessica Nicole Kumar 560 8 Line Rd Lecanto, FL 34461

File No. 86607

Dear Applicant:


We have received an official transcript mailed directly from a massage therapy school, however it is not on counterfeit-proof paper as required by Rule Title 64B7-32.002(2)(a), FAC. Please have your school send a transcript printed on counterfeit-proof paper or you may file a petition for variance or waiver of the rule requirement. Instructions can be found: http://www.f|oridahealth.gov/Iicensing-and-regu|ation/declaratory/variance.html

We are unable to verify the approval of your massage therapy school. Please have your massage therapy school submit proof of approval by the equivalent State licensing agency or State Department of Education in which it is located.

Our office has received your transcript, but cannot verify that each category of required hours has been satisfied. Please have your school complete the enclosed form and submit it to our office, outlining the courses that fulfill the category requirements for licensure.


You may follow the progress of your application through our website at: http://ww2

' ' Once there, select your profession and enter your usernameWto check your application status. If we require further

documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.



P1NTEREST: Han/Fla

Sincerely,


Wm WW Katrina Hopkins Regulatory Specialist I


Rick Scott Governor








December 9, 2015 Jessica Nicole Kumar 560 S Line Rd Lecanto, FL 34461


We have not received proof of completion of a three (3) hour HIV/AIDS course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school, Florida Board approved continuing education provider, or the American Red Cross. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. We have not received your Livescan results. If you have already had your electronic fingerprinting (Livescan) completed, please allow 24-72 hours for receipt of your results. The Board of Massage Therapy cannot accept hard copy (paper) fingerprint cards. All applicants must have electronic fingerprinting completed by a Florida Department of Law Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.floridahealth.gov/licensing-and-regulation/background-screening/index.html Please use the electronic fingerprint form found in the application or on our website at: http://floridasmassagetherapy.gov/resources/ We have not received proof of completion of a two (2) hour prevention of medical errors course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. We have not received a passing score directly from the Federation of State Massage Therapy Boards (FSMTB). Please contact the FSMTB and have them release your score to our office. They may be reached at 1-866-962-3926 or at www.fsmtb.org. We have not received an official transcript containing the school seal, on counterfeit-proof paper, mailed directly from a massage therapy school. The school must be approved by the

_ _ Rick Scott Mussmn: Toprded, manna/en's health ______ Gwemor

0f?“ We in Floridamrugwimagraled John H Armstron . . 9, MD, FAcs stale,oomty&oannnflyefiofis.

HEALTH StaleaxgemGeneramSeaeiary


December 9, 2015

Jessica Nicole Kumar 560 8 Line Rd Lecanto, FL 34461

File No. 86607

Dear Applicant:




All applicants must have electronic fingerprinting completed by a Florida Department of Law Enforcement (FDLE) approved provider. For a list of approved providers and a list of Frequently Asked Questions visit our website at: http://www.f|oridahealth.gov/Iicensing-and- reguIation/background-screening/index.html

Please use the electronic fingerprint form found in the application or on our website at: http://f|oridasmassagetherapy.gov/resources/



We have not received an official transcript containing the school seal, on counterfeit-proof paper, mailed directly from a massage therapy school. The school must be approved by the

www.FloridaHealIl1.gov Florida Department of Health TWITTERHeaflhyFLA Dvision of Nbdcd Qafly Woe - mm of HCPR FACB3CDK FLDepa'mmlofl-Iealm 4052 dO/pmmVWy, BinCXB- Talmessee, FL3Z’QQ3256 YOUTIBE: fidoh

PHCNE (850)2454444 - FAX: (850)4122681 FLICKR Heath/Fla PINTEREST: HedthyFla

equivalent State licensing agency or State Department of Education in which it is located. We have not received proof of completion of a ten (10) hour Florida laws and rules course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com. We are unable to verify the approval of your massage therapy school. Please have your massage therapy school submit proof of approval by the equivalent State licensing agency or State Department of Education in which it is located. Our office has received your transcript, but cannot verify that each category of required hours has been satisfied. Please have your school complete the enclosed form and submit it to our office, outlining the courses that fulfill the category requirements for licensure. We have not received verification of your license(s) directly from the licensing agency. Verification must indicate dates of licensure, method of licensure, and if there has been any discipline/complaints.

Include the above file number on all correspondence to our office. Please be advised any information received by our office may require additional explanation and/or documents to determine your licensure eligibility. As a reminder, Section 456.013(1)(a), Florida Statutes, states an incomplete application shall expire one year after initial filing with the department. You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your username kumarjes and password 3!26712mK to check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation. If you should have any questions pertaining to this matter, please do not hesitate to contact our office by email at [email protected] or at the address below.

Sincerely,


equivalent State licensing agency or State Department of Education in which it is located.

We have not received proof of completion of a ten (10) hour Florida laws and rules course as required by Section 456.013(7), F. S. Course must be taken from a Florida Board approved school or Florida Board approved continuing education provider. For Board approved courses contact CE Broker at 1-877-434-6323 or www.CEBroker.com.

We are unable to verify the approval of your massage therapy school. Please have your massage therapy school submit proof of approval by the equivalent State licensing agency or State Department of Education in which it is located.

Our office has received your transcript, but cannot verify that each category of required hours has been satisfied. Please have your school complete the enclosed form and submit it to our office, outlining the courses that fulfill the category requirements for licensure.

We have not received verification of your |icense(s) directly from the licensing agency. Verification must indicate dates of licensure, method of licensure, and if there has been any discipline/complaints.


You may follow the progress of your application through our website at: http://ww2.doh.state.fl.us/mqaservices/login.asp Once there, select your profession and enter your usernam— Check your application status. If we require further documentation or information to process your application, this will also be viewable. If you have submitted the information requested or on the website above, please allow 10 working days for the processing of this documentation.


Sincerely,

W 4W9


FSMTB /’ FEDERATION OF STATE

Ill/ll MASSAGE THERAPY BOARDS

FSMTB 2016 RESOLUTIONS

Dear FSMTB Member Boards and Agencies,

Voting on resolutions will commence during the FSMTB Annual Meeting October 8, 2016.

Enclosed are five resolutions for consideration. The Georgia Board of Massage Therapy has submitted two resolutions. The Indiana State Board of Massage Therapy has also submitted two resolutions. The fifth resolution from the New Jersey Board of Massage and Bodywork is a carryover from the FSMTB 2015 Annual Meeting.

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Resolution Form

Title of Resolution: Eligibility Criteria for Access to MBLEx: Substantiating Documentation

Member Board/Committee Proposing Resolution: Georgia Board of Massage Therapy

WHEREAS the Georgia Board of Massage Therapy (Board) requires applicants for licensure as massage therapists to verify graduation from an education program as one criterion for licensute eligibility; and

WHEREAS the Board requires applicants for licensure to successfiflly complete the Massage and Bodywork Licensing Examination (MBLEx) owned and administered by the Federafion of State Boards of Massage Therapy (F SMTB) as one criterion for licensure eligibility; and

WHEREAS current F SMTB policies allow candidates to register for, receive an Authorization to Test letter (ATT), and sit for the MBLEx by attesting to having obtained flm education and training in all subject areas of the ABLEx Content Outline; and

WHEREAS, current FSMTB registration policies require candidates seeking access to the MBLEx to self-identify without verification the education program currently attending or having completed; and

WHEREAS the Board has identified an increased number of applicants for licensure that indicate a difl'erent education program than that idenfified when registering with FSMTB for the MBLEx, and

WHEREAS FSMTB may, under certain circumstances where there are identified discrepancies in education programs, impose adverse actions against such candidates including invalidation of MBLEX scores; and

WHEREAS FSMTB adverse actions against such candidates may have an efl'ect on the licensure process administered by the Board, and

WHEREAS allowing candidates who have registered for the MBLEX under an inaccurate education program may adversely or undeservingly affect the pass/fail and retest rates attibutable to the identified education program, and WHEREAS accurate identification of education programs will decrease the number of adverse actions that may have to be taken by FSMTB, and

THEREFORE, BE IT RESOLVED that the FSMTB Board of Directors amend its MBLEX registration policies to include, as a prerequisite to access to the MBLEx, a

requirement that candidates shall cause their educafion program(s) to submit directly to FSMTB verification of having obtained the education and training in all subject areas of the AlBLEx Content Outline and/or substantiation of graduation from an FSMTB member board approved or State approved massage therapy education program.

THEREFORE, BE IT FURTHER RESOLVED that such new policies have an effective date as soon as reasonably possible but, under any circumstances, no later than July 1, 2017.

IMPLEMENTATION PLAN FSMTB will make changes in policy and take necessary actions to implement the Georgia Board of Massage Therapy Resolution for MBLEx Eligibility for any candidate that will sit for the MBLEX exam on or after July 1, 2017.

Board Members Board Director Craig Knowles, LMI‘ Adrienne Price Chair Executive Director

Jennifer Clay, LMT Vice Chair

Board Attorney Pam Nichols, LMT Betsy Cohen, Esq.

Assistant Attorney General Trisha Butler, LMT

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Resolution Form

Title of Resolution: Amendment to Re-testing/Re-examination Policy to Limit the Number of Attempts to Pass the MBLEx Before Additional Education and Training is Required


WHEREAS the Georgia Board of Massage Therapy proposes that the F SMTB Board of Directors amend the re-testing/re—exmnination policy to state that after a failed fifih (5th) attempt at passing the examination, the candidate must provide FSMTB with verification of having taken additional education and training in all content subject areas from a board approved massage therapy education program before being allowed to retake the examination.

WHEREAS allon the same students or individuals to retake the examination as many times as they wish allows for greater opportunity to commit test fraud through the memorization of the test questions and the sharing of that information with other test candidates.

WHEREAS the Georgia Board of Massage Therapy reasons that statistics regarding the probability of an individual passing an exam after more than two attempts diminishes with each additional attempt as a result of a loss in confidence, little time to study between attempts or little time to complete a remediation plan to increase professional insight.

WHEREAS the Georgia Board of Massage Therapy reasons that FSMTB has invalidated scores for individuals who have passed the MBLEX with high scores after multiple attempts upon discoven'ng that the candidate participated in exam fraud.

THEREFORE BE IT RESOLVED that the statements noted above are hereby approved, ratified and adopted by the members of the Georgia Board of Massage Therapy.

RESOLVED, that implementation of these measures may further reduce the incidences of test fraud.

RESOLVED, that passage rate for second time test takers will improve and positively affect the pass/fail rates for the appropfiate schools as candidates will focus more on studying when they know that the number of attempts to pass the exam is limited.

IMPLENIENTATION PLAN — Should the policy be amended, it will be incorporated in the MBLEX Candidate Handbook in the ‘Application and Documentation Requirerhents, ’

Muthenficity and Adequacy, ’ ‘Fraud, Cheating and F arfeiture, ’ ‘Haw Many Times Can I Take

The AlBLEx? ’ and the ‘Retaking an Examination ’ sections.

EFFECTIVE DATE — The Georgia Board of Massage Therapy would like the see the proposed

amendment effective as soon as possible and no later than the calendar year 2017. Upon motion duly made by Pam Nichols, LMT, seconded by Jennifer Clay, LMT and Unanimously canied, said resolution is to be forwarded to FSMTB for consideration.

Board Members Board Director Craig Knowles, LMT Adrienne Price Chair Executive Director Jennifer Clay, LMT Vice Chair

Board Attorney Pam Nichols, LMT Betsy Cohen, Esq.

Assistant Attorney General Trisha Butler, LMT

Resolution Form

Title of Resolution: MBLEx Eligibility Resolution A. ISMTB

Member Board/Committee Proposing Resolution: Indiana State Massage Therapy Board

WHEREAS, massage therapy or massage and bodywork therapy education and the skills that are developed in the training is what prepares a person to work safely and competently on the public; and

WHEREAS, developing a knowledgeable, skilled and competent professional strengthens their career and ensures a safer and more satisfactory experience for the public and the massage therapist; and

WHEREAS, requiring the completion of an individual’s education to sit for the MBLEx exam will help state boaId members and staff that review state licensing applications and attached supporting documents, to decipher what school was attended, how many hours of education was completed, and whether each individual state law requirements are met, making the whole validating process as clear as possible; and

WHEREAS, implementation of this resolution will help to address the increasing problem of fiaudulent documents slipping through the vetting process at all levels; and

WHEREAS, each level of the journey that an individual goes through to become a state licensed/certified massage therapist, including the school they attend, the tests they take and the state they apply to for credentials should do their part to protect the public fiom harm and ensure an individual is a trained professional in the massage therapy and bodywork field; and

WHEREAS, portability for a massage therapist could prove to be more acceptable from state to state when the completion of their education requirement is met; and

WHEREAS, this resolution is in alignment with the mission of the FSMTB, which is “The mission of the Federation is to support its Member Boards in their work to ensure that the practice of massage therapy is provided to the public in a safe and effective manner.”

THEREFORE BE IT RESOLVED, that candidates applying for the MBLEx exam complete and pass course work required for graduation from an approved / accredited massage therapy or massage and bodywork therapy education program that meet their state requirements to be eligible to sit for the MBLEx exam.

IMPLEMENTATION PLAN 0 FSMTB make changes in policy and take necessary actions to implement the Indiana

State Board of Massage Therapy Resolution for MBLEx Eligibility- 0 Candidates approved to sit for the MBLEx exam, prior to the effective date, would not

experience a change to their “Authorization to Test (ATT)” date to test, which is 90 days from their approval date.

Fiscal Note Attached, if necessary Indiana State Board of Massage Therapy is unable to estimate the minimal fiscal impact.

EFFECTIVE DATE As of January 1, 2017, all candidates applying to sit for the MBLEx exam will be required to complete a massage therapy or massage and bodywork therapy education program prior to taking the exam.

Resolution Form

Title of Resolution: MBLEx Eligibility Resolution B. ISBMT

Member Board/Committee Proposing Resolution: Indiana State Board of Massage Therapy

WHEREAS, state boards and staff process applications for individuals seeking state licensing/certification for the massage profession. They attcmpt to decipher whether the person attended massage school, what is the name and location of the school, is it a creditable school, how many hours was the program, what dates are listed for starting and completion of the program, did they finish the program, when did they take the MBLEx exam and do the dates make any sense. Challenges include, the name of the school on the application isn’t the same name listed on the MBLEX Jurisdictional Score Report and Transfer GTade Roster. The report shows the applicant failed the exam 10/30/13, retake 12/17/15 passed. Different school name and dates on the report, but passed the MBLEx before completions of the finish date and the school on the report is no longer open for business. With a personal appearance the applicant brings in a school diploma and other supporting documents. Documents and dates don’t match up, school names don’t match up, papers are notarized but they passed MBLEx. How did they get this far into the process of becoming a massage therapist with this much confusion? This is a frequently seen scenario that state boards deal with; and

WHEREAS, sorting through the levels of the vetting process to validate an applicant should not be done at the end of the journey. Determining if documents have been tampered with or if mistakes have been made should be done throughout the process at every level; and

WHEREAS, state boards are most concerned about the public’s safety and granting a license/certification to someone who has rightfully earned that privilege; and

WHEREAS, requiring proof fi‘om a candidate by submitting supporting documentation that they completed a massage therapy or massage and bodywork therapy program to validate that accomplishment is the most sensible way to fight against confusion, mistakes that slip through the process, fraudulent documents being accepted, and meefing our ethical obligations and responsibility of a state board, under their authon'ty, in issuing a license; and

WHEREAS, this resolution is in alignment with the mission of the FSMTB and carrying it out, which is, “The mission of the Federation is to support its Member Boards in their work to ensure that the practice of massage therapy is provided to the public in a safe and effective manner.”

THEREFORE BE IT RESOLVED, that candidates applying for the MBLEx exam must submit documentation supporting proof of completion and passing course work required for graduation from an approved / accredited massage therapy or massage and bodywork therapy

education program, that meet their state requirements, to the FSMTB in the manner necessary for verification prior to being eligible to sit for the MBLEx exam, in addition to all other requirements outlined in the candidate handbook.

IMPLEMENTATION PLAN 0 FSMTB make changes in policy and take necessary actions to implement the Indiana

State Board of Massage Therapy Resolution for MBLEx Eligibility. - Candidates approved to sit for the MBLEX exam, prior to the effective date, would

not experience a change to their “Authorization to Test (ATT)” date to test, which is 90 days from their approval date.

Fiscal Note Attached, if necessary Indiana State Board of Massage Therapy is unable to estimate the fiscal impact.

EFFECTIVE DATE As of January 1, 2017, all candidates applying to sit for the MBLEX exam will be required to submit supporting documentation of their completion of a massage therapy or massage and bodywork therapy education program before being approved to sit for the MBLEx exam.

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Resolution Form

Title of Resolution: NIBLex Eligibilifl

Member Board/Committee Proposing Resolution: NJ State Board Massage and Bodywork Therapv

WHEREAS Candidates who apply for the exam are required to declare the massage school of attendance, including the dates of attendance and the graduation date of that program. In signing the application, the candidate is required to verify that they have read the Examination Content Outline and that they have education and training in the content subject axeas.

Currently there is no mechanism attached to the application process that requires evidence of completion of a massage training program. Although in the “STATENIENT OF ACKNOWLEDGEMENT: I hereby certifi} that the information I provided on this application and in any supporting documents is accurate, true, and correct to the best of my knowledge and belief ”, there is no requirement to submit supporting documents of attendance and graduation of a massage therapy program. That not all states require completion of an approved training program ml a passing score of an approved exam. There are documented cases in which candidates have taken and passed the MBLex only to be determined at a much later date that the test scores were found to be invalid. These determinations have occurred after these candidates have been granted licenses based on passing scores, which in turn, gives them the opportunity to apply for a license in other States by endorsement. This ultimately compromises Consumer Protection and Public Safety.

THEREFORE BE IT RESOLVED:

That candidates for the MBLex, be required to submit evidence of completion of a massage training program before being permitted to sit for the MBLex.

FISCAL CONSIDERATION:

This resolution would require extra time from staff to: o amend the application 0 review evidence for accuracy

IMPLEMENTATION PLAN: 0 a change in the application to sit for the MBLex is needed to reflect the need for

supporting documents in evidence of a massage training program 0 a change in job tasks for the stafl' member charged with this responsibility is also needed

Fiscal Note Attached, if necessary: 0 A fiscal analysis would be required to define an outline for this aspect of this proposed

resolufion.

EFFECTIVE DATE: 0 Within 180 days from the approval of this resolution.

2016 Resolution Recommendations from the FSMTB Policy Committee

1. Title of Resolution: Eligibility Cn'teu'a for Access to MBLEx: Substantiating Documentation


Policy Committee Recommendation: Pass

2. Title of Resolution: Amendment to Re-testing/Re—examination Policy to Limit the Number of Attempts to Pass the MBLEx Before Additional Education and Training is Required.


Policy Committee Recommendation: Do Not Pass

3. Title of Resolution: MBLEx Eligibility Resolution A. ISBMT

Member Board/Committee Proposing Resolution: Indiana State Massage Therapy Board


4. Title of Resolution: MBLEx Eligibility Resolution B. ISBMT

Member Board/Committee Proposing Resolution: Indiana State Board of Massage Therapy


5. Title of Resolution: MBLex[sic] Eligibility New Jersey (tabled 2015)

Proposed in 2015 by former FSMTB Member: New Jersey Board of Massage and Bodywork Therapy


Board of Massage Therapy FLORIDA

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