4401-890661 Sarais Mendoza HAL

Ron DeSantis
Mission: Governor
To protect, promote & improve the health
of all people in Florida through integrated Joseph A. Ladapo, MD, PhD
state, county & community efforts. State Surgeon General
Vision: To be the Healthiest State in the Nation
February 22, 2024
*Confidential*
Sarais L Figueroa Mendoza
715 Fazzini Rd
Babson Park, FL 33827
Profession Code: 4401

File number: 890661
Dear Applicant:
The Department of Health received your criminal history results. This letter is to acknowledge receipt of
those results and does not replace anything requested in the application deficiency letter.
We are mailing you an application amendment form due to information found on your application that
conflicts with the results on the report. The enclosed form gives you the opportunity to modify your
response to the criminal history question.
Your criminal background check has disclosed an arrest record(s). Please see the enclosed
page for any offenses requiring additional documentation.
In order to continue processing your background screening you will need to provide
documentation related to every criminal event in your background. Such documentation may
include:
• Self-Explanation – a letter written in your own words that describes the

circumstances surrounding each offense, including date, city, state, charges, plea,
and disposition/sentencing. If the offense involved battery or assault, you must
include your relationship to the victim and the age of the victim at the time the
offense occurred in this explanation.
• Court Dispositions/Sentencing – documentation from the county Clerk of Courts in

the jurisdiction (state/county) in which the offense(s) occurred, including
disposition/final outcome and sentencing (showing what was ordered, examples:
probation, fines, etc.). You may be able to obtain this online through the clerk of court
website. NOTE: Please have all alias/maiden names included in the search.
• Arrest Report(s) – a copy of the arrest report for each offense. If you are unable to
obtain a copy from the Clerk of Court, you can request a copy from the arresting
agency.
• Probation/Parole, PTI Letters and/or Release (if applicable) – proof that you
completed all court ordered probation/parole, PTI (Pre-trial intervention) or jail time
ordered. This documentation must be issued by the probation office, Department of
Corrections or the jail and must include the start date and termination date of your
probation or supervised release.
• Receipt of Payment (if applicable) – proof that all fines, restitution, or other court
costs have been paid in full for each offense. This documentation can be obtained
from the Clerk of Court in the county in which the offense occurred and must include
the date in which the payment/completion of the sanction was satisfied.
If you are unable to produce the information required above, a letter (on letterhead) from the Clerk of
Court within the jurisdiction of the offense is required and must state the reason the document is not
available. NOTE: Please have all alias/maiden names included in the search.
The Department of Health will not be able to complete the review process of your application until the
requested documentation is received.
Please return a copy of this letter along with all requested documents to
MQA.BackgroundScreen@flhealth.gov, or by fax (850) 617-6290 or mail:
Background Screening Unit
Attn: A. Mccary
Florida Department of Health
4052 Bald Cypress Way, Bin BSU-01
Tallahassee, FL 32399-3260
For any additional questions, please contact our office by phone (850) 245-4272, fax (850) 617-6290 or
visit our website at http://www.flhealthsource.gov/background-screening/.
Sincerely,
A. Mccary
Government Analyst I
APPLICATION UPDATE
CRIMINAL HISTORY (Review Questions & Answers section in instructions.)
A. Yes 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 adjudication was withheld. Driving under the influence
(DUI) or driving while impaired (DWI) is not a minor traffic offense for purposes of this
question.
B. No I have NEVER 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 adjudication was withheld.) Driving under the influence
(DUI) or driving while impaired (DWI) is not a minor traffic offense for purposes of this
question.
If you answered NO, because the charges were dismissed or nolle prossed, you must submit
documentation for the county clerk of courts in the jurisdiction (state/county) in which the offense occurred,
including disposition/final results. Your application will not be considered complete until these records
are received.
If the records are no longer available, you must obtain a letter of their unavailability from the county clerk of
the court.
Failure to notify the Board office of any changes in any responses on your application could result
in the delay of application processing, denial of your application or revocation of licensure.
Examples: change of name, address, telephone number, arrest or convictions, licensure status or
disciplinary action in another state or an incorrect answer to a question.
APPLICANT SIGNATURE
I, the undersigned, state that I am the person referred to in this application for licensure in the State of
Florida.
I affirm these statements are true and correct and recognize that providing false information may result in
disciplinary action against my license or criminal penalties pursuant to sections 456.067, 775.083 and
775.084, Florida Statues.
I have carefully read the questions in the foregoing application and have answered them completely, without
reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by
me herein are true and correct. Should I furnish any false information in this application I hereby agree that
such act shall constitute cause for denial, suspension, or revocation of my license to practice as a
Registered Nurse or Licensed Practical Nurse in the State of Florida.
I further state I have read and understand Chapter 464, Florida Statutes, and Chapter 64B-9, Florida
Administrative Code, as they pertain to the practice of nursing. (Note: A current copy of Chapter 464 and
Chapter 64B-9 may be obtained by calling (850) 488-0595 or via the internet at
http://www.doh.state.fl.us/mqa/.)
Florida Law requires you to immediately inform the Board of any material change in any circumstances or
condition stated in the application which takes place between the initial filing and the final granting or denial
of the license and to supplement the information on this application as needed.
I affirm that I will comply with all requirements for licensure renewal including continuing education credits.
Applicant’s Signature___________________________________ Date _________________

Sarais L Figueroa Mendoza
Profession: 4401 Applicant ID: File # 890661
Supplemental Background Screening Information:
Offense(s):
Date of Offense:10/31/2023
Offense Description: NO VALID DRIVERS LICENSE
Arresting Agency: POLK COUNTY SHERIFF'S OFFICE

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Ron DeSantis

Vision: To be the Healthiest State in the Nation

February 22, 2024

Profession Code: 4401

• Self-Explanation – a letter written in your own words that describes the

• Court Dispositions/Sentencing – documentation from the county Clerk of Courts in

CRIMINAL HISTORY (Review Questions & Answers section in instructions.)

Applicant’s Signature___________________ Date _

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