facility_name: Bar None Residential Services

raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”

Report Number: 202600402

Date Issued: April 28, 2026

Name and Address of Facility Investigated:

Bar None Residential Services
22426 Saint Francis Blvd
Anoka, MN 55303

Disposition: Maltreatment Determined as to sexual abuse and neglect of an alleged victim by a staff person.

Maltreatment Determined as to neglect of an alleged victim by four staff persons and the facility.

License Number and Program Type:

1036848-CRF (Children’s Residential Facility)

Investigator(s):

Scout Peterson
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242

Scout.peterson@state.mn.us

(651) 431-6578

Suspected Maltreatment Reported:

It was reported that a staff person (SP) digitally penetrated and kissed a 13-year-old alleged victim (AV), allowed the AV to use his/her personal cell phone to watch pornography and interact with strangers online, and provided him/her a vape that contained THC. It was also alleged that staff persons and the facility failed to report the maltreatment as required.

Date of Incident(s): September 21, 2025

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 20; and subdivision 15, paragraph (a), clauses (1) and (2):

"Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on January 21, 2026; from documentation at the facility, law enforcement and medical records; and through four interviews conducted with the AV, P1, P3, and the AV’s guardian ad litem (GAL). This investigator met the SP where s/he was incarcerated, however, at the advice of his/her attorney, the SP did not provide information to this investigator. The SP provided information to law enforcement and in the facility’s Internal Investigation that was included below. This investigator met and interviewed the AV but did not ask questions specific to the allegations of sexual assault, as a forensic interview was already completed and information from the forensic interview was included below. This investigator attempted to contact P2 by phone and s/he did not respond to voicemail messages, but s/he did provide information for the facility’s Internal Review that was included below. The AV’s family member (FM) was contacted but did not have additional information to provide. This investigator had initial contact with another staff person (P4) and later attempted to contact P4 through emails to get further information, but attempts were unsuccessful.

On September 23, 2025, the incident was initially reported to the Department, and on December 19, 2025, additional information was received. Information provided at those times showed that statements collected from staff persons and security camera footage from the facility contradicted the AV’s narrative of what reportedly occurred.

The AV was 13 years old and diagnosed with major depressive disorder, reactive attachment disorder, posttraumatic stress disorder, and generalized anxiety disorder. On May 20, 2025, the AV moved to the facility for services and supports related to his/her diagnoses. The AV did not have a diagnosed seizure disorder, but it was noted in the AV’s intake paperwork to “rule out conversion disorder (non-epileptic seizures and spells vs possible malingering).”

At the time of the incident, the AV lived on the Haven unit. The unit was a square-shaped room with a main common area with multiple bedrooms on two sides that faced each other. At one end was the entrance to the unit and on the other side was the staff office. The AV’s bedroom was at the end of the row of bedrooms, nearest to the staff office.

According to an incident report dated September 21, 2025, at 3:40 a.m. the AV woke up and told the SP that s/he did not feel well. Approximately 15-20 minutes later the AV said that s/he did not feel “safe,” and that s/he may harm him/herself, so the SP put a chair by the AV’s bedroom door and continually checked in with him/her. The AV then lay down on his/her side and s/he appeared to have a seizure. The SP called P3 who advised the SP to continue monitoring the AV and talk to him/her “calmly” until s/he was again verbally responsive. When the AV started to speak again, s/he asked the SP to call 911 because s/he was feeling “unsafe” and wanted to self-harm. The SP told the AV that was “not an option”, and the AV could talk to the SP about what was going on. The following morning, at 7:58 a.m., P1 called P3 and said that the AV stated s/he was “touched” by an overnight staff person. The AV repeatedly asked both P1 and P3 to call 911 or “the hotline” to report what happened, but they stated they could not. Later that night, the AV was on the phone with his/her therapist, hung up the phone, and called 911. Sheriff’s deputies went to the facility and spoke with the AV and other staff persons and stated that the AV needed to be taken to the hospital for a sexual assault examination.

The AV provided the following consistent information to this investigator, to the facility, to law enforcement, and through a forensic interview:

· During the morning hours of September 21, 2025, the SP touched the AV’s genitals, showed the AV his/her genitalia, kissed the AV on the lips and chest, and sucked on the AV’s nipples. The SP let the AV use the SP’s phone to watch pornography and chat with unknown persons online using the “Monkey App.” [Note: Monkey is an app that is for people over 18 and connects users with random strangers via video chat. There is concern about sexual advertisements and pornographic/illegal content shared between users in video chats.]

· Later that morning, after P1 and P2 arrived for work at the facility, the AV told them what happened but they “did not believe” the AV. Sometime later that day, the AV was talking to his/her therapist about what happened and then called 911 to report it. The AV stated that s/he “started a crisis” because s/he wanted to “make sure [s/he] was getting someone to listen to [him/her].”

· Law enforcement came to the facility, talked to the AV, and told staff persons at the facility that the AV needed to be taken to the hospital for a sexual assault examination. The AV was taken to the hospital and returned later the same day.

· The AV also reported that the SP gave the AV a vape that contained THC. The vape was green and had a “Chinese girl” on the side.

According to the AV’s medical record, on September 22, 2025, the AV received a sexual assault nurse examiner (SANE) exam. During the exam, multiple speckled substances fluoresced on each of the AV’s nipples under ultraviolet light which led the nurse to take swabs of the substances present. The nurse also took vaginal and perineal swabs from the AV.

According to information provided by law enforcement:

· On September 21, 2025, at 5:02 p.m., law enforcement officers (LEO) responded to the facility in response to the AV’s call to 9-1-1. The AV told 9-1-1 dispatchers that s/he was suicidal, wanted to go to the hospital, and that s/he had been sexually assaulted. A staff person who was not identified further in the law enforcement report told officers that the AV had a history of lying to staff persons. That morning the AV screamed and accused the SP of “sexual contact,” but “administration” believed the accusation to be “unfounded.” The AV told LEO that s/he was sexually assaulted by a staff person and LEO told facility staff persons to take the AV to the hospital for a sexual assault exam. At 7:12 p.m. LEO cleared the scene and left the facility.

· Cameras at the facility were motion-activated and only recorded if there was motion detected in an area that the camera captured. For the period of 3:47–7:12 a.m. there was over 60 minutes of time when the cameras did not record. At 5:40 a.m. the SP walked towards the AV’s room and went behind the door to his/her room and then the camera shut off. At 6:00 a.m. the SP was seen walking in the direction of the AV’s door then the camera shut off. At 6:10 a.m. the SP walked away from the AV’s room and into the common area as the door closed behind him/her. At 6:13 a.m. the SP went back into the AV’s room and closed the door; the camera cut out until 6:42 a.m. where the SP can be seen sitting in a chair by the AV’s door.

· On September 23, 2025, LEO met with the SP and the SP stated that s/he never touched the AV in a sexual manner. The SP stated that on September 21, 2025, the AV told the SP that s/he was “feeling dizzy” and wanted the SP to call 9-1-1, but the SP told the AV s/he could not, and the AV went to his/her room. When the SP went to the AV’s room to check on him/her, the AV told the SP that s/he wanted to kill him/herself, so the SP put a chair near the AV’s door to “monitor” him/her. The AV “fell” by the door of his/her bedroom and again asked the SP to call 9-1-1 which s/he did not. The AV paced back and forth around his/her room and again “dropped to the floor.” The SP went into the AV’s room, picked him/her up by the arms, and put him/her into his/her bed. The SP went back to the staff office, and the AV followed him/her. The AV tried to get the phone to call 9-1-1, but the SP stopped him/her. The AV then left the office and began yelling “[the SP] touched me!”

· The LEO asked the SP if the AV made any “sexual advances” towards the SP, and the SP stated that the AV “started doing some weird moves,” and took off his/her shirt leaving only a bra. The AV then tried to touch or grab the SP, but the SP stated that s/he “did not know and did not want to know” what part of the SP’s body the AV was trying to touch. The SP told law enforcement that s/he called P3 one time that morning, between 4:30 and 5:30 a.m. The SP’s phone log showed that the SP called P3 from his/her cell phone at 7:46, 7:48, and 7:58 a.m. When asked if s/he owned a vape pen, the SP told LEO that s/he did not own one and that s/he had asthma. The SP had “no idea” why the AV would say that the SP gave him/her a vape pen, and “did not know how that could be possible.”

· On October 16, 2025, the LEO met with the SP again and obtained a sample of his/her DNA and cell phone. Information extracted from the SP’s phone showed that on September 21, 2025, at 5:57 and 6:11 a.m. the SP’s cell phone accessed pornographic websites and at 5:57 and 6:09 a.m. the SP’s cell phone was used to access “Monkey App” on the internet browser application. The SP told the LEO that while s/he was trying to “control” the AV, the AV took the SPs phone, had it for “several minutes,” and accessed those websites without his/her permission.

· On November 18, 2025, the examination of the DNA evidence collected from the AV and the SP was complete. Information showed that amylase (saliva) samples collected from each of the AV’s nipples matched the sample of the SP’s DNA. On January 6, 2026, the LEO met with the SP to discuss the new information and the SP told the LEO that saliva was present on the AV’s nipples because s/he “must have been drooling a lot” when s/he picked up the AV and put him/her into his/her bed. On January 7, 2026, the SP was arrested and charged with one count of first degree criminal sexual conduct.

The SP provided the following information for the facility’s Internal Review:

· The morning of September 21, 2025, the AV had a “tantrum” or “medical problem,” and was shaking. The SP called P3, who instructed the SP to stay close to the AV and talk to him/her and make sure s/he was “okay.” The SP stated that s/he did what P3 told him/her to do and lifted the AV from the floor into his/her bed by lifting the AV by the arms. The SP stated s/he also held the AV’s hand.

· When asked if the door was open or shut, the SP stated that s/he “hoped” it was open, but “there were times” that the AV was “loud,” so the SP closed the door. The SP stated that s/he did not think s/he was supposed to be in the AV’s room “at all,” but was “just trying to help.” Later the same night, when the SP was in the staff office, the AV went into the office and refused to leave. The SP stated that in order to get the AV out of the office, s/he “embraced” the AV and took him/her back to his/her room. While the SP did so, the AV was “angry” and called out “help, help, help.” The SP stated that all the other residents woke up, came out of their rooms, and it was a “nightmare” after that.

· The SP stated that s/he never touched anyone, including the AV, inappropriately and did what s/he “thought [s/he] had to do” to help the AV. The SP stated that s/he was there to “help” and not to “do anything bad.” The Internal Review did not include information from the SP regarding the AV’s use of his/her cell phone or a vape.

P3 provided the following information in an interview with this investigator and in the facility’s Internal Review:

· On September 21, 2025, around 4 a.m., P3 received a call from the SP that the AV appeared to be having a seizure. The AV “faked seizures to get attention” in the past so P3 told the SP to stay “nearby” and have verbal contact with the AV. P3 stayed awake for an unknown amount of time watching the cameras remotely, before falling asleep and did not see anything notable. P3 stated that if the AV was on the floor, the SP should have left him/her on the floor and made sure the area around was “safe and secure,” it was not procedure to lift the AV off the ground at any point during a potential medical emergency.

· Later that morning after morning shift staff persons arrived, one of the staff persons (P3 could not remember who) called and informed P3 that “something happened” overnight, and that the SP “molested” the AV overnight. The other morning staff person (who P3 could not remember) called and stated that the SP and AV “touched each other” and “shared a vape.” P3 then escalated the concerns to P4 “immediately.” P3 did not remember who “called in” to report the information to DHS or law enforcement.

· Staff persons were not to use or have their personal phones on their person when working on the unit. P3 encouraged staff persons to use the facility phone or their walkie talkies to communicate while at the facility. Staff persons were also not permitted to have any drugs (including THC and nicotine) on facility grounds unless hidden and locked in one’s personal vehicle. Staff persons were not permitted to enter clients’ personal rooms unless there was a second staff person there to visibly watch the other staff person while inside.

· There were prior reports made that alleged the SP watched pornographic videos on his/her phone during shifts. P3 stated that for the time frames reported, security camera footage did not corroborate the reports. P3 added that the SP typically sat in an area where his/her phone screen could be “very clearly” seen by cameras.

In an interview with this investigator and in the facility’s Internal Review P1 stated that on the morning of September 21, 2025, when s/he arrived at the facility for his/her shift, the AV was waiting for him/her by the door and said that the SP “raped” him/her. The AV said s/he asked the SP if s/he should take off his/her clothes and the SP replied “yes.” The AV also told P1 that the SP gave him/her a green vape. P1 called P3, who then reviewed the cameras from the night prior and told P1 that the SP was never in the AV’s room, only in the doorway like s/he was “supposed to” be. P1 added that the AV made unfounded allegations about maltreatment by staff persons of the opposite gender in the past. On an unknown date (later determined to be September 29, 2025), P1 took the AV to a follow up doctor appointment and stated that the doctor said that the SP’s DNA was not found anywhere on the AV. [Note: according to information provided by law enforcement, the serology exam of the SP’s DNA and evidence collected during the sexual assault exam was not released until November 18, 2025, and there were no notes in the AV’s medical record for September 29, 2025, that showed the DNA results were discussed at the appointment.]

As part of the facility’s Internal Review, P2 stated that on September 21, 2025, s/he worked an 8 a.m. to 10 p.m. shift. The AV told P2 that the SP touched him/her “inappropriately,” “raped” him/her, and was “very vulgar” with what s/he said. The AV then stated that it was “consensual” and that s/he took off his/her clothes in exchange for a vape. P2 stated that for the rest of the day, the AV “wouldn’t stop telling us the same stuff but changing it,” and that s/he could not help the AV get “regulated” no matter what s/he tried to do.

The GAL worked with the AV since 2024 and stated that s/he had a history of negative interactions with staff persons and previously made inaccurate reports about staff persons, but nothing “as severe” as the alleged sexual assault. The GAL stated that the AV was a “very good advocate” for him/herself. The AV told the GAL that s/he “did not feel listened to” by staff at the facility about the incident but was “very open” to speaking about it.

Information provided by the facility showed that there were previous concerns reported regarding the SP watching pornography during his/her shifts at the facility. Previously reported concerns showed that on August 1, 2025, a client at the facility saw the SP touching him/herself sexually in the bathroom through a door that was “propped open.”

According to the facility’s Emergency Procedures Plan, staff persons were to remain on scene and notify the on-call supervisor in the event of any incident. In the event of a medical event, the staff person should call the on-call nurse for guidance unless it was a life-threatening emergency in which case the staff person should call 9-1-1. If a client experienced a mental health crisis, the staff person called the on-call mental health professional.

According to the facility’s Substance Use Policy, staff persons were prohibited from the use, possession, distribution, dispensation, or transfer of substances, including THC/marijuana at any worksite. Staff persons were also prohibited from being under the influence of any substance while working. The facility’s Nonsmoking policy stated that the staff persons were permitted to use vaping products in designated outdoor areas.

According to the facility’s Reporting of Minor Maltreatment, staff persons were required to report suspected abuse or neglect to the appropriate investigative agency immediately or within 24 hours. Staff persons were not permitted to “shift the responsibility” of reporting to a supervisor or anyone else at the facility; staff persons were required to report the information to an outside investigative agency themselves.

Information provided by the facility showed that P1-P4 and the SP were each trained on the Reporting of Maltreatment of Minors Act and the above-mentioned policies/procedures.

Relevant Rule/Statute

Minnesota Statutes, section 609.234, subdivision 1, clause (1) states in part that any mandated reporter who is required to report under section 626.557, who knows or has reason to believe that a vulnerable adult is being or has been maltreated and who intentionally fails to make a report is guilty of a misdemeanor.

Minnesota Statutes section 609.342, subdivision 1a, paragraph (e) stated that a person who engaged in sexual contact with a person greater than 36 months younger and under 14 years of age was guilty of criminal sexual conduct in the first degree.

Minnesota Statute, section 342.09, subdivision 1, paragraph (b), clause (7) stated in part that an individual may not give cannabis to an individual under 21 years of age.

Minnesota Statute, section 260E.06, subdivision 1, paragraph (a) stated in part that a person who knows or has reason to believe a child was being maltreated shall immediately report the information to the local welfare agency responsible for investigating the report or law enforcement.

Minnesota Statutes, section 245C.15, subdivision 4(b)(1), stated that individuals who fail to report maltreatment which was serious or recurring can be disqualified from working in direct contact positions with persons receiving services in facilities licensed by the Department of Human Services, the Department of Health, the Department of Corrections, and in Personal Care Provider Organizations.

Conclusion:

A. Maltreatment:

Regarding Sexual Abuse

Information provided in the AV’s medical record and in law enforcement information showed that during the AV’s SANE exam, speckled fluorescence appeared under ultraviolet light that indicated potential bodily fluid. After the DNA test results returned, it was confirmed that there was amylase (saliva) that matched the SP’s DNA on each of the AV’s nipples. The AV provided varied but similar information to facility staff persons and the forensic interviewer about what occurred. Additional consistent information surrounding the circumstances of the abuse was provided by the AV to law enforcement and this investigator.

Although the SP denied any sexual contact with the AV, given that after the AV’s initial disclosure s/he provided detailed and consistent information about the incident to multiple people, that the SP had reason to minimize his/her actions with the AV, and that physical DNA evidence showed the SP’s DNA on the AV’s nipples which supported his/her statements of what occurred, there was a preponderance of the evidence that the SP had sexual contact with the AV.

It was determined that sexual abuse occurred (“sexual abuse” means the subjection of a child by a person responsible for the child’s care, by a person who has a significant relationship to the child, or by a person in a position of authority, to any act that constitutes a violation of 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.)

Regarding Neglect

The AV provided consistent information that the SP provided the AV with a THC vape pen during the time of the sexual assault. In addition, the SP allowed the AV to use his/her phone to watch pornographic videos and chat with strangers online. Information provided by law enforcement after forensic examination of the SP’s phone corroborated the AV’s account of what s/he did on the SP’s phone. The AV was interviewed by facility administrative staff persons, law enforcement, a forensic interviewer, and this investigator about the allegations of vape use and watching pornography on the SP’s phone and s/he provided consistent information.

There was no information provided that the AV was harmed from using the SP‘s vape. However, s/he was under 21 years old and therefore, it was illegal for a person to give marijuana to him/her and the SP encouraged him/her to participate in actions that were illegal. In addition, the SP’s conduct of giving the AV a vape and allowing the AV to use his/her phone to watch pornography was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP denied doing so, given that the AV provided consistent information about the alleged maltreatment, that law enforcement substantiated the AV’s claim through forensic evidence, that s/he watched pornography on the SP’s phone, and that the SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the incident occurred as described by the AV. Therefore, there was a preponderance of the evidence that the SP provided the AV with a vape and allowed the AV to use his/her personal cell phone to watch pornography and interact with strangers online, which was a failure to supply the AV with necessary care and a failure to protect the AV.

It was determined that neglect occurred (the failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child’s physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so.)

Regarding Failure to Report

Minnesota Statute section 260E.06, subdivision 1, requires that a mandated reporter who “knows or has reason to believe a child is being maltreated” shall immediately report the information to the local welfare agency, agency responsible for assessing or investigating the report, police department, county sheriff, tribal social services agency, or tribal police department.

P1-P3 each provided consistent information that during the morning they told their respective supervisors about what the AV reported, however, at no time did P1-P3 report the information to law enforcement or the Division of Licensing for investigation, nor did they take steps to ensure the AV obtained a SANE exam. P3 said that s/he reported to P4 that morning but law enforcement information showed that they did not arrive on the scene until 5:02 p.m. only after the AV called 9-1-1. LEO responded to the facility, talked to the AV and staff persons, told staff persons to take the AV to the hospital, and left. Given that P1-P4 were all mandated reporters, that they each had reason to believe that maltreatment occurred as the AV reported the incident to them, that they did not report the information as required by statute, and that only after the AV called 9-1-1 him/herself did s/he receive the care necessary for a reported assault, there was a preponderance of the evidence that P1-P4’s conduct was a failure to supply the AV with necessary care and services. Additionally, given that the AV called and reported the sexual assault him/herself, after four staff persons with various levels of authority failed to report the incident, and that without the AV reporting the incident him/herself the alleged sexual assault would have not been investigated there was a preponderance of the evidence that the facility failed to respond to a sexual assault and supply the AV with necessary care and services.

It was determined that neglect occurred (the failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child’s physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so.)

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2):

When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

The SP was trained on the Reporting of Maltreatment of Minors Act, the facility’s Reporting of Minor Maltreatment and Substance Use policies prior to the incident. The SP was responsible for maltreatment of the AV.

It was determined that P1-P4 were each aware of the incident hours after it occurred as P1-P3 each reported to his/her supervisor after becoming aware of what the AV reported. However, staff persons did not report the incident externally as required. P1-P4 had the information throughout the day and did not report it for further investigation. P1-P4 were each responsible for the neglect of the AV. The facility failed to ensure multiple staff persons at various levels of authority reported the alleged sexual assault so therefore the facility was also responsible for the neglect of the AV.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. The Office of Inspector General is also required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.”

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

Minnesota Statutes, section 245C.15, subdivision 4, paragraph (b), clause (1), states:

An individual is disqualified under section 245C.14 if less than seven years has passed since a determination or disposition of the individual’s failure to make required reports under section 260E.06 for incidents in which: (i) the final disposition under section 260E was substantiated maltreatment, and (ii) the maltreatment was recurring or serious.

It was determined that the substantiated sexual abuse for which the SP was responsible was “serious” maltreatment because the AV sexually abused the AV. The SP was disqualified from providing direct contact services.

It was determined that the substantiated neglect for which the SP was responsible was considered “recurring” maltreatment because the SP allowed the AV to use his/her phone to watch pornography and allowed the AV to use his/her vape that contained marijuana, which constituted two separate incidents. The SP was disqualified from providing direct contact services.

It was determined that the neglect for which P1-P4 was responsible was not recurring or serious maltreatment. Although criminal sexual conduct occurred between the SP and AV, P1’s-P4’s failure to report was not the cause of the sexual contact. However, P1-P4 failed to report maltreatment for which the final disposition was serious and recurring. Therefore, P3 and P4 were each disqualified from providing direct contact services.

It was determined that the neglect for which the facility was responsible was not serious maltreatment because although criminal sexual conduct occurred between the SP and the AV, the facility’s failure to report was not the cause of the sexual contact.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Division of Licensing for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate and followed. Staff corrective action was not deemed necessary and the facility offered staff persons optional trainings to support staff persons in “protecting themselves from potential false reporting.”

Action Taken by Department of Human Services, Office of Inspector General:

P3, P4, and the SP were each disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that P3, P4, and the SP were responsible for maltreatment and their disqualifications are each subject to appeal.

P1 and P2 were notified that each was responsible for serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that P1 and P2 were responsible for maltreatment is subject to appeal.

On April 28, 2026, the facility was issued a $1000 fine as a result of the substantiated maltreatment for which the facility was responsible. The facility was also issued a $200 fine for failing to report maltreatment as required. The maltreatment determination and the Order to Forfeit a Fine is subject to appeal.

Certification:

The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Maltreatment Finding


state: MN

raw_content:
April 28, 2026                    CERTIFIED MAIL

Katie Perzel, Authorized Agent

Bar None Residential Services

7625 Metro Blvd Suit 200

Minneapolis, MN 55439-3057

License Number 1036848 (Children’s Residential Facility)

Report Number 202600402

DETERMINATION OF MALTREATMENT

FAILURE TO REPORT MALTREATMENT

AND ORDER TO PAY A FINE

Dear Katie Perzel:

The Department of Human Services (DHS) determined that Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN, 55303, is responsible for maltreatment by neglect and failure to report maltreatment. Based on this determination, DHS is ordering you to pay a fine of $1200. Details of our findings are provided below and in the enclosed Investigation Memorandum for report 202600402. Our next steps and your options are also detailed.

I. Determination of Maltreatment

It was reported that a staff person (SP) digitally penetrated and kissed a 13-year-old alleged victim (AV), allowed the AV to use his/her personal cell phone to watch pornography and interact with strangers online, and provided him/her a vape that contained THC. It was also alleged that staff persons and the facility failed to report the maltreatment as required.

DHS investigated the report as alleged maltreatment by sexual abuse and neglect. Maltreatment was determined as to sexual abuse and neglect of the the AV by the SP and neglect of the AV by four staff persons and the facility.

Based on the maltreatment investigation, DHS determined that Bar None Residential Services was responsible for neglect of the AV. See the enclosed Investigation Memorandum for more information.

Legal Authority: Minnesota Statutes, section 260E.30, subdivision 2, paragraph (a).

Fine: $1,000

II. Failure to Report Maltreatment

Based on the maltreatment investigation, DHS determined that mandated reporters including supervisory and/or administrative staff persons had knowledge of the incident of possible maltreatment, but did not make a report as required.

Legal Authority: Minnesota Statutes, section 260E.06, subdivision 1.

Fine: $200

Corrective Action Required: Within 30 days of receipt of this order, submit written documentation to your DHS licensor showing that all staff have been retrained on the reporting requirements for alleged maltreatment. The documentation must identify: names of staff persons completing the training; staff person’s qualifications, the date of the training; the number of hours of the training, who provided the training and the training materials.

Repeat Violation: The license holder was cited for a similar violation in Correction Orders issued on November 27, 2025, and February 3, 2026.

Submissions required as part of the corrective action ordered must be sent to your Licensor at:

Commissioner, Department of Human Services

ATTN: Hannah Horsch

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

III. Order to Pay a Fine

Because DHS determined that Bar None Residential Services is responsible for maltreatment by neglect and failure to report maltreatment, you must pay a $1200 fine.

Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), subparagraph (4).

IV. Billing and Payment of the Fine

DHS will send you an invoice for the $1200 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is personally responsible for payment.

If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

V. YOUR RIGHT TO APPEAL

You have right to appeal the maltreatment determination and/or fine. Please see options below.

Should you exercise your rights to appeal send:

1.

Certified mail to:

Personal delivery to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Right to appeal the fine and maltreatment determination

You have the right to appeal the fine and maltreatment determination. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 15 calendar days from when you received this order. See address, Section V.

If your request is being personally delivered, it must be received by DHS within 15 calendar days from when you received this order. See address, Section V.

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order.

2. Request for reconsideration of the maltreatment determination only

If you do not appeal the fine, you may still request reconsideration of the maltreatment determination. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to request reconsideration began when you received this order.

Your request must:

· Be in writing

· Clearly state that you are requesting reconsideration of the maltreatment determination

· Identify what is inaccurate or incomplete about the information in the Investigation Memorandum

· Supply information that is accurate or more complete

· State why you believe the finding of maltreatment should be changed

· Be made before the deadlines provided below.

Your request must be postmarked within 15 calendar days from when you received this order. See address, Section V.

A response to your reconsideration request will be mailed within 15 working days after DHS receives your request. You have the right to request a fair hearing if a response is not mailed within 15 working days.

3. Right to appeal the order to pay a fine only

You have the right to only appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. See address, Section V.

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. See address, Section V.

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order.

4. Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.justice4mn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4), item (i) provides that DHS may impose a $1000 fine for each determination of maltreatment of a child under section 260E for which the license holder is determined responsible.

· In determining whether the facility, an individual, or both are responsible for substantiated maltreatment, DHS must consider the mitigating factors provided in Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2).

· DHS may impose a $200 fine for each health, safety, or supervision licensing violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4), item (iv).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

· License holders have a right to request reconsideration of a maltreatment determination, under Minnesota Statutes, section 260E.33, subdivision 2, paragraph (a) and (b).

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

Questions

If you have any further questions regarding this matter, you may contact Tessa Ripka, Unit Supervisor, at 651-308-2314.

Sincerely,

Maggie Hanson, Intake and Investigations Unit Manager

Office of Inspector General

Licensing Division

Enclosure

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


raw_content:
April 27, 2026

Katie Perzel, Authorized Agent

Volunteers of America of Minnesota

7625 Metro Blvd Suite 200

Minneapolis, MN 55439

License Number:   1036848

Report Number:   202502675

202504293

202504367

202504588

202505639

202506348

CORRECTION ORDER

Dear Katie Perzel:

A Department of Human Services (DHS) licensor conducted a licensing investigation of your facility, BarNone Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN 55303. This investigation was conducted to determine compliance with state and federal laws and rules governing the provisions of children’s residential facilities under Minnesota Rules 2960. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

DHS determined that your program did not follow licensing rules and statutes, as described below.

Policy and Practice

1. Violation: The license holder’s policy for the safe storage and delivery of medicine did not meet requirements. The plan did not include how the license holder would transfer medications and ensure a continuation of administration when a resident is temporarily placed at a facility outside of the license holder’s care.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the policy for safe storage and delivery of medication meets requirements. Within 30 days of receipt of this order, submit a policy of safe storage and delivery of medication that demonstrates compliance.

2. Violation: The license holder’s practice for critical incident reports did not meet requirements. The license holder did not submit a critical incident report for incident dated May 17, 2025 when residents were brought the emergency department by emergency personnel.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A

Repeat Violation: In a Correction Order that DHS issued on March 13, 2026, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the practice for critical incident reports meets requirements.

3. Violation: The license holder’s practice did not ensure residents’ right to live in clean, safe surroundings. The license holder had a room on the living unit that was utilized as a chicken coop.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item H

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the practice for resident rights meets requirements.

Personnel Files

4. Violation: The license holder did not follow through with correction action steps as described in their internal review dated June 10, 2025. SP1 was not retrained on restrictive procedures.

Statue Violated: Minnesota Statutes, section 245A.66, subdivision 1

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a correction action plan is completed as determined. Within 30 days of receipt of this order, submit documentation SP1 has been trained according to the corrective action plan.

Resident Files

5. Violation: Two of two resident files reviewed for requirements governing no eject did not meet requirements. The file did not contain documentation of the following:

a. License holder conferred with other interested persons to review the issues involved in the decision (R1);

b. Whether additional strategies to resolve the issues leading to the discharge could have been developed to allow the resident an opportunity to continue to receive services (R1 and R2); and

c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted (R1 and R2).

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the no eject process meets all applicable requirements. Within 30 days of receipt of this order, submit no eject documentation for two residents that demonstrates compliance.

6. Violation: One resident file was reviewed for requirements governing resident screening (R1) and did not meet requirements. The file did not contain documentation the vulnerability assessment was completed within six working days of admission.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, item C

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident screening meets all applicable requirements.

7. Violation: Three of three resident files reviewed for requirements transition services plan (R3 through R5) did not meet requirements. The file did not contain documentation of the following:

a. The transition service plan was not completed prior to the resident’s release from the program;

b. The plan did not include the following:

1. Recommend ways to meet the resident’s continuing needs after release from the facility;

2. Consider the environment into which the resident will return, and recommend how the resident may deal with issues and potential challenges within that environment;

3. Developed with input from the resident, resident’s family members, if appropriate, and the persons who will provide support services to the resident upon release.

4. Housing, recreation, and leisure arrangements;

5. Appropriate educational, vocational rehabilitation, or training services;

6. A budget plan and a description of the resident’s financial and employment status;

7. Transportation needs;

8. Treatment services;

9. Health services; and

10. Personal safety needs.

c. A copy of the plan given to the resident.

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure transition services plans meet requirements. Within 30 days of receipt of this order, submit a transition service plan for two residents that demonstrates compliance.

8. Violation: One resident file was reviewed for requirements governing informed consent (R6) and did not meet requirements. The file did not contain documentation the license holder obtained informed consent prior to administration of a psychotropic medication.

Rule Violated: Minnesota Rules, part 2960.0620, subparts 6, item A

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure informed consent meets requirements.

Written Response Required

If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

If submissions are required as part of the corrective action ordered they must be sent to your licensor by email at ginny.benson@state.mn.us or by mail at:

Commissioner, Department of Human Services

ATTN: Ginny Benson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violation(s). Your request must:

· Be in writing

· List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6957 or at ginny.benson@state.mn.us

Sincerely,

Ginny Benson, Senior Licensor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Correction Order


report_date: February 11, 2026

raw_content:
February 11, 2026

Katie Perzel, Authorized Agent

Volunteers of America of Minnesota

7625 Metro Blvd, Suite 200

Minneapolis, MN 55439

License Number: 1036848 (CRF)

CORRECTION ORDER

Dear Katie Perzel:

On January 13, 2026, DHS Licensing received 2 critical incident reports from your facility, Bar None Haven, located at 22426 Saint Francis Boulevard, Anoka, Minnesota 55303. As a result, DHS is issuing this order which requires you to take the correction action as described below. Details of our findings, next steps, and your options are explained below.

LICENSING VIOLATIONS

DHS determined that your program failed to follow licensing rules and statutes, as described below.

Program Practices

1. Violation: The license holder did not meet critical incident reporting requirements. The following incidents met the definition of a critical incident and were not submitted to DHS within 10 days of learning of the incident, they were submitted late:

a. December 11, 2025

b. December 30, 2025

Statute Violated: Minnesota Statutes, section 245I.13.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the reporting of critical incidents meets all applicable requirements.

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

· List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-2410 or at alyssa.nelson@state.mn.us.

Sincerely,

Alyssa Nelson, Licensor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


report_date: February 3, 2026

summary: CORRECTION ORDER

raw_content:
February 3, 2026

Katie Perzel, Authorized Agent

22426 Saint Francis Blvd

Anoka, MN 55303

RE:  Report No. 202504033

Bar None Residential Services

License No. 1036848

Dear Katie Perzel:

CORRECTION ORDER

An investigation of Bar None Residential Services was completed regarding report number 202504033 which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegation concerned neglect. The disposition of the investigation report is maltreatment not determined. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

The following violation of state and (or) federal laws and rules was observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violation within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

Citation: Minnesota Statutes, section 260E.06, subdivision 1.

Violation: A person who knows or has reason to believe a child is being maltreated shall immediately report the information. “Immediately” means as soon as possible but in no event longer than 24 hours.

During the course of the investigation, it was determined that staff persons at multiple levels of authority were aware on May 3, 2025, of possible maltreatment that occurred on April 29, 2025. The Department of Human Services was not aware of the report until May 14, 2025.

Corrective Action Ordered: Immediately and on an ongoing basis, you must maintain compliance with the requirements of Minnesota Statutes and report any incident of suspected maltreatment immediately or within 24 hours.

If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, .

Sincerely,

Scout Peterson, Investigator

Office of Inspector General

Licensing Division

Enclosure

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


report_date: September 18, 2025

summary: CORRECTION ORDER

raw_content:
September 18, 2025

Katie Perzel, Authorized Agent

Bar None Residential Services

7625 Metro Blvd, Suite 200

Minneapolis, MN 55439

RE:  Report No. 202506569

Bar None Residential Services

License No. 1036848

Dear Katie Perzel:

CORRECTION ORDER

An investigation of Bar None was completed regarding report number 202506569, which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, part 2960. This maltreatment allegation concerned neglect. The disposition of the investigation report is maltreatment not determined. Two violations were noted.

VIOLATIONS AND CORRECTION ORDERS

The following violation of state and (or) federal laws and rules was observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

1. Citation: Minnesota Rules, part 2960.0710, subpart 5

Violation: One resident file was reviewed for requirements governing physical escort requirements (R1) and did not meet requirements. A physical escort was not used to control a resident who was guided to a place where the resident would be safe and to help de-escalate interactions between a resident and others.

Documentation of a physical escort on July 15, 2025, stated a staff person used a physical escort because the resident had stolen food, and the purpose of the escort was to retrieve the food from the resident.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure physical escort requirements meet all applicable requirements.

2.  Citation: Minnesota Rules, parts 2960.0050, subpart 1, item D; and 2960.0110, subpart 2.

Violation: The license holder’s practice of resident rights and physical environment of comfort, privacy, and dignity (R1 and R2) did not meet requirements. The license holder did not ensure the resident’s right to positive and proactive adult guidance, support and supervision. The license holder did not ensure the physical environment provided for the comfort, privacy, and dignity of residents.

On July 15, 2025, R1 and R2 were allowed to sleep in a “studio room” that is not a designated sleeping space. The residents slept on the same mattress on the floor and used the same blanket to share. Through staff interviews, it was determined there were items in the studio room that the residents had used to use to self-harm that were not removed. Additionally, through staff interviews, it was also determined the studio room door remained closed and staff completed period visual checks on the residents.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the practice for resident rights and physical environment of comfort, privacy, and dignity meets all applicable requirements.

If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Alyssa Nelson at 651-431-2410.

Sincerely,

Beth Virden, Senior Investigator

Office of Inspector General

Licensing Division

651-431-6572

Enclosure

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”

Report Number: 202406881

Date Issued: May 28, 2025

Name and Address of Facility Investigated:

Bar None Residential Services
22426 Saint Francis Boulevard
Anoka, MN 55303

Disposition: Maltreatment determined as to neglect of an alleged victim by two staff persons.

License Number and Program Type:

1036848-CRF (Children’s Residential Facility)

Investigator(s):

Kim Anderson/Beth Virden
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
kimberly.huett.anderson@state.mn.us

651-431-6553

Suspected Maltreatment Reported:

It was reported that staff bought chemical hair removal cream for an alleged victim (AV), which caused a chemical burn under the AV’s arms.

Date of Incident(s): August 6, 2024

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2):

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 9, 2024; from documentation at the facility; and through seven interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1 and SP2), supervisory staff persons (P1 and P2), and a facility nurse (P3).

A Diagnostic Assessment stated that in June 2024, the AV moved into the facility seeking residential treatment for “emotional and behavioral concerns.” The facility provided therapy, psychiatry, and daily programming. The AV was 16 years old.

The facility was a locked building with multiple staff providing mental health services to youth ages 11 to 17.

The facility’s Incident Report, dated August 6, 2024, stated the following:

At around 6:50 p.m., [the AV] requested to take a shower and use [chemical hair removal cream] that [SP1] bought for them that day. Staff allowed [the AV] to use cream under supervision, telling them they had to be in eyesight while using the cream. [SP2] set a timer for [the AV] so they could notify them when it was time to wipe it off. [The AV] began to wipe cream off, and asked for staff assistance from [SP1] due to [the AV’s] armpits burning and itching. [SP2] immediately called [P3], in which [SP2] was told to get the remainder of the cream off and treat it with Vaseline (over-the-counter skin protectant/petroleum jelly). [SP2] rinsed the area, let it air dry, and applied Vaseline.

On the morning of August 7, 2024, at an unspecified time, staff photographed the AV’s left underarm and provided a copy for this investigation. A red circle stretched beyond the underarm area with flaking skin and streaks of darker red in the skin creases. A measuring device was not included. [Note: Information was provided that both of the AV’s underarms had similar symptoms. The AV’s right underarm was not photographed.]

The AV provided the following information:

· The AV saved up his/her “bar none bucks,” which were a facility perk for youth to get extra snacks. When a youth reached 100 bar none bucks, they could ask staff to do a store run for specific items. The AV saved up to 100 and asked staff to buy him/her chemical hair removal cream. The AV had never used chemical hair removal cream before but wanted an alternative to shaving.

· SP1 bought the cream and gave it to the AV.

· The AV did not test if s/he was allergic to the cream prior to applying. Instead, the AV immediately applied the cream to his/her legs. The cream remained for ten minutes and then the AV wiped it off. The AV’s leg hair was removed without issue. The AV then applied the cream to his/her underarms. However, within a few minutes, both of the AV’s underarms were “burning.” The AV wiped the cream off and his/her underarms hurt “really bad” and were bleeding.

· SP1 and SP2 were both aware the AV was using the hair removal cream and/or were present, supervising the AV during the process.

· The AV believed the hair removal cream was on his/her underarms for ten minutes but the burning sensation started before that. Once the cream was removed, SP1 or SP2 applied ointment to the AV’s underarms. It took a few weeks for the AV’s underarms to fully heal. The healing process was “really bad” and “hurt.”

The FM said that the staff did not ask his/her permission for the AV to use chemical hair removal cream. If they had asked, the FM would have said, “No,” because of the AV’s family history with “extremely sensitive” skin. The cream caused the AV’s underarms to “peel” and “blister.”

The facility’s Internal Review, SP1, SP2, P1, P2, and P3 provided the following information:

· SP1 said that on an unspecified date, the AV gave him/her a list of items to buy at the store using his/her 100 bar none bucks; the list included brownie mix and chemical hair removal cream. SP1 bought the items and told P1 about the items s/he purchased, including the hair removal cream. According to SP1, P1 saw the hair removal cream and said that it was “fine.” SP1 then gave it to the AV. [Note: The hair removal cream was put in the AV’s shower caddie, which was kept at the staff desk.]

· SP2 said that on an unspecified date and time, s/he watched the AV, in the living room, apply the hair removal cream under both of his/her arms. SP2 set a timer to remove the cream per the packaging instructions. When the timer alarmed, the AV went into the bathroom to wipe the cream off but soon came out “in pain and frantic.” SP2 saw that both of the AV’s underarms had “red skin peeling off in layers … a little bleeding … very raw.”

· The facility’s Internal Review stated that SP2 said the timer was set for ten minutes. According to the facility’s camera system, the AV applied the cream at 6:49 p.m. and at 6:51 p.m., SP2 helped wipe it off of the AV’s underarms.

· SP1 saw that the AV’s underarms had “a good layer or two (of skin) burned off. There was a “decent amount of peeling and speckled tiny bit of blood.” “Very raw.”

· SP1 and SP2 each said that SP2 called P3 and told him/her that the skin was raw, peeling, and bleeding.

· P3 recalled this phone call and said that SP2 told him/her the AV’s underarms were “red.” SP2 did not say anything about the AV’s underarms bleeding. P3 determined the AV sustained a “mild chemical burn” from the hair removal cream, which did not require urgent care. P3 told SP2 to offer the AV over-the-counter pain reliever, Vaseline, and/or ice but the AV “refused all treatment” from P3. The next morning, August 7, 2024, staff sent a picture of the AV’s left underarm (described above). P3 called the facility’s medical director who agreed that the AV did not need to be seen in urgent care. The doctor wrote an order for Desitin Ointment (rash cream/skin protectant) as needed for a “chemical burn” under the AV’s arms. Staff picked up the Desitin that same day and began applying to the AV’s underarms right away. P3 never saw the AV’s underarms in-person. P3 did not have concerns with how the incident was handled by staff or the doctor’s treatment plan. [Note: Desitin is available as an over-the-counter product.]

· P1 and P2 each said that chemical hair removal cream was prohibited at the facility and was listed as being prohibited in the staff orientation training documents. P1 said that SP1 did not say anything to him/her about the hair removal cream prior to giving to the AV and that s/he learned of it after the incident.

· SP1 said that s/he read through the list of prohibited items in the staff orientation training documents but did not notice the prohibition of chemical hair remover and said that it was an “absent of mind on my part.”

· SP2 said that when SP1 bought the chemical hair remover, SP2 “didn’t think anything of it. I trusted it … I didn’t know it was prohibited. Had no idea.”

The facility’s Program Handbook, dated May 2024, stated that residents on “phase 2” of programming may use a razor to shave during hygiene time. “No chemical hair removal products can be used.”

According to the packaging of the chemical hair removal cream used by the AV:

WARNINGS: IRRITATION OR ALLERGIC REACTION MAY OCCUR WITH SOME PEOPLE, EVEN AFTER PRIOR USE WITHOUT ADVERSE EFFECT. THEREFORE, TEST BEFORE EACH USE BY APPLYING PRODUCT TO A SMALL PART OF THE AREA WHERE HAIR IS TO BE REMOVED. FOLLOW DIRECTIONS AND WAIT 24 HOURS. IF SKIN APPEARS NORMAL, PROCEED WITH FULL APPLICATION. DO NOT USE ON IRRITATED, SUNBURNED, INFLAMED, OR BROKEN SKIN. KEEP AWAY FROM EYES. SHOULD PRODUCT TOUCH THE EYES, WASH THOROUGHLY WITH LUKEWARM WATER. IF IRRITATION OCCURS, DISCONTINUE USE. IF IRRITATION PERSISTS, CONSULT YOUR PHYSICIAN. DO NOT USE ON FACE, AROUND EYES, IN NOSE, IN EARS, OR ON BREAST NIPPLES, PERIANAL, OR VAGINAL/GENITAL AREAS. KEEP OUT OF REACH OF CHILDREN. (emphasis in original)

According to healthline.com:

[Chemical hair removal creams] can burn your skin, even if you use them as intended … There are remedies and over-the-counter methods to treat depilatory (hair removal) burns at home … See a doctor if your burn appears to be getting worse. If your blisters start to ooze pus or turn yellow, you should see a doctor immediately as this could be a sign of a more serious infection.

Facility documentation stated that SP1, SP2, P1, P2, and P3 received training on the facility’s Program Handbook and the Reporting of Maltreatment of Minors Act. P3 was not required to receive training on the faciilty’s Program Handbook.

Conclusion:

A. Maltreatment:

The AV, the FM, SP1, SP2, and P1-P3 provided consistent information that at the AV’s request, SP1 bought chemical hair removal cream for the AV and the AV applied it under his/her arms while supervised by SP1 and SP2 and sustained a chemical burn. SP2 called P3, who advised that the AV did not need urgent care and could be treated at the facility with over-the-counter pain reliever, Vaseline, and ice. A doctor was contacted the next morning, who ordered as needed Desitin cream. The AV said that his/her underarms took a few weeks to fully heal and was “really bad” and “hurt.”

The AV was living at the facility to receive residential treatment for “emotional and behavioral concerns.” The AV was 16 years old and relied on staff to provide his/her care and supervision at the facility. The Program Handbook, dated May 2024, stated, “No chemical hair removal products can be used.”

Given that SP1 purchased and provided to the AV a chemical hair removal product which was prohibited by the facility, that SP1 and SP2 then supervised the AV using the prohibited item, that SP1 and SP2 failed to follow the instructions that stated, “TEST BEFORE EACH USE BY APPLYING PRODUCT TO A SMALL PART OF THE AREA WHERE HAIR IS TO BE REMOVED. FOLLOW DIRECTIONS AND WAIT 24 HOURS. IF SKIN APPEARS NORMAL, PROCEED WITH FULL APPLICATION,” and that the AV sustained an injury directly relating to his/her use of the chemical hair removal product, there was a preponderance of the evidence that there was a failure by staff to supply the AV with necessary care required for the AV’s physical or mental health when reasonably able to do so and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical health when reasonably able to do so.

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2):

When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

SP1 and SP2 were responsible for the AV’s care and supervision. Although SP1 said that s/he did not recall hair removal cream being listed as a prohibited item and SP2 said that s/he did not know hair removal cream was prohibited, SP1 and SP2 each received training on the facility’s Program Handbook which stated, “No chemical hair removal products can be used.” SP1 and SP2 were also trained on the Reporting of Maltreatment of Minors Act.

SP1 purchased the chemical hair removal cream which was a prohibited item and gave it to the AV. SP1 and SP2 then each supervised and allowed the AV to use the prohibited item in addition to not ensuring that the directions were followed.

SP1 and SP2 were each responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious. Although the AV sustained a chemical burn under her arms, it was treated with over-the-counter products and did not require the care of a physician whether or not the care of the physician was sought.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility retrained the staff involved “on practices in the handbook, specific to health and hygiene and rules regarding shaving and the use of chemical products.” The staff involved and/or the AV were not part of any similar, past events.

Action Taken by Department of Human Services, Office of Inspector General:

SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP1 and/or SP2. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal.

Certification:

The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.

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