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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: 202203335

Date Issued: July 15, 2022

Name and Address of Facility Investigated:

Jelani House
221 Belvidere Street E
Saint Paul, MN 55107

Disposition: Maltreatment determined as to physical abuse of an alleged victim by a staff person.

License Number and Program Type:

1100893-CRF (Children’s Residential Facility)

Investigator(s):

Carla Harvieux
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6616

Suspected Maltreatment Reported:

It was reported that a staff person (SP) punched an alleged victim (AV) several times because the AV declined to be searched when s/he returned to the facility after a community outing.

Date of Incident(s): April 19, 2022

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a):

"Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on May 12, 2022; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP), and the AV’s guardian (G).

The facility provided services to youths with the goal of successfully reintegrating them with their families and communities, and offered them case management services for up to 12 months after youths completed the program at the facility. There was a video recording system with audio at the facility that recorded common areas inside the facility and the area just outside the facility’s main entrance.

Facility documentation showed that the AV had a history of declining to follow rules and had previous contact with the court system. The AV did not like others to use raised voices with him/her or repeat themselves in conversation with the AV, and did not want to feel “singled out.” Attending school regularly was a goal for the AV, and s/he wanted to live as independently as possible. At the time this report was written, the AV no longer resided at the facility.

Facility documentation, information from the SP, P1, and P2, interviews with this investigator, videos from the facility’s recording system, and information from the facility’s Internal Review, provided the following:

· The AV could not be located for an interview with this investigator, but video and audio recordings made by the facility’s recording system showed that the AV declined to be searched after a community outing on the evening of the incident. The AV entered the facility, and attempted to move past the SP, who then tried to block the AV’s progress. The AV pushed the SP twice. The second push occurred near the top of a flight of stairs, and the SP had difficulty maintaining his/her balance. When the AV declined to be searched, the SP contacted P1 by telephone, and went to the office. The SP could be heard saying that the AV put his/her hands on the SP which s/he considered “totally unacceptable.” The SP also said that if s/he put his/her hands on the AV, s/he would “fucking kill” the AV.

· The AV then came to the door and said “what’s up?” several times. The SP opened the door and then tried to close it forcefully, but the AV attempted to keep the door open. Several punches were exchanged between the SP and AV and both were hit, but it was unclear which punches connected. The SP pulled/threw the AV onto the floor in the office, punched him/her several times on the torso, held the AV on the floor with his/her arms around the AV’s head and chest, and wrapped his/her legs around the AV’s torso/legs at one point. The AV called out for assistance to other youths who resided at the facility, but the youths did not assist the AV. The SP said, “Are we done?” multiple times, declined to release the AV, and both the AV and SP used profanity. The AV asked the SP to release him/her but the SP told the AV that s/he got his/her “ass beat” and did not release him/her. A few seconds later, the SP released the AV and asked him/her not to hit the SP.

· The SP and AV walked between the office and kitchen, continued to use raised voices, and the AV repeatedly asked the SP to go outside to fight. The SP walked away from the AV, and the AV followed him/her, continuing the verbal exchange. The AV attempted to knock a bottle of water from the SP’s hand, shoved the SP in the back several times, followed the SP making threatening statements, used profanity and racial slurs toward the SP, and asked the SP to fight him/her several times. The SP told the AV that s/he had already fought him/her, had beat him/her, that s/he was “folded up” in the office, and that s/he was “easy.” The SP asked the AV to leave him/her alone many times but also mocked the AV for asking for help from other youths who resided at the facility when the SP held the AV on the office floor. The physical exchange and hold in the office lasted for roughly five minutes.

· The SP said that the facility was “hands off” for staff persons and youths, meaning they should not have physical contact. On the date of the incident, the AV declined to allow the SP to use a metal detecting wand to search him/her after the AV returned from a community outing, which was against facility policy according to the SP. The AV became upset and shoved the SP, which nearly caused the SP to fall down a flight of stairs. The SP contacted P1, a facility case manager, who talked with the AV by phone, and the SP went to the office to “let out some of the adrenaline that was in [his/her] system.” After the AV and P1 talked, the AV gave the SP the phone, and the SP talked with P1 in the office. While the SP and P1 were talking, the AV opened the office door, stood in the doorway, and began saying that s/he wanted to “fight” the SP. The SP attempted to close the door, but the AV “forced” the door open and punched the SP “in the face.” Documentation written by the SP showed that the AV “threw several more punches,” then the SP “threw [the AV] to the ground and punched [him/her] back a few times.” On the floor, the SP restrained the AV and asked him/her if they could “end the fight” if the SP released the AV. The AV declined, but eventually the SP ended the restraint and remained on the floor with his/her hands extended out and upward, asking the AV if they could end the fight. The SP said that s/he was careful not to place the AV in a “choke hold” and felt that his/her actions were in self-defense. P1 and law enforcement officers soon arrived at the facility, and P1 instructed the SP to leave the facility for the day and assessed the AV for injuries, but did not observe any.

· P1 and P2 provided consistent information that staff persons were expected to search youths when the youths returned from community outings. P2 said that youths were asked to turn their pockets inside out, be “wanded” using metal detecting wands, and have quick pat searches done by a staff person who was the same gender as the youth. If a youth declined to be searched and it was thought that the youth had a dangerous item, the youth would not be permitted inside the facility. If staff persons felt threatened by a youth, they were to call the law enforcement agency, and if a youth pushed his/her way into the facility, staff persons were to document the youth’s actions, then notify the youth’s case manager, who would come to the facility to talk with him/her. On the morning of April 20, 2022, (the day after the incident), the AV was evaluated by a health care professional and no injuries were noted.

· Records were requested from the law enforcement agency, but had not been received when this report was completed.

The facility’s policy regarding “discipline” stated that staff persons were to ensure that discipline was applied fairly and consistently to maintain consistent consequences and ensure the safety of the facility, its residents, and staff persons. Staff persons were not to use aversive consequences including the use of corporal punishment, rough handling, shoving, ear or hair pulling, shaking, slapping, kicking, biting, punching, hitting, throwing objects or spanking when working with the youths. In addition, staff persons were not to engage in name calling, make derogatory statements about the youth’s race, gender, disability, sexual orientation, religion or culture, or make statements intended to shame, threaten, humiliate, or frighten the youth. Restrictive techniques or procedures as punishment were prohibited.

The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Maltreatment of Minors Act prior to the incident.

Conclusion:

A. Maltreatment:

Information was consistent that on April 19, 2022, the SP had a physical interaction with the AV in the office. Video/audio recordings showed that the SP restrained the AV by placing his/her arms around the AV’s head and chest, and wrapping his/her legs around the AV’s torso/legs. Prior to the incident, the SP said that the AV’s actions were unacceptable and that s/he would “fucking kill” the AV.

In a phone call, the SP told P1 that the AV declined to be searched and pushed the SP. The AV then entered the office, physical contact between the SP and AV began, the AV and SP punched each other, and the SP restrained the AV on the floor for about five minutes. During the restraint, the SP told the AV that s/he got his/her “ass beat,” and after the restraint, the SP told the AV that s/he had “beat” the AV, “folded up” the AV, that the AV was “easy,” and mocked the AV for asking for help from other youths during the restraint, which was not verbal de-escalation and cumulatively caused the AV to remain upset.

The SP told this investigator that the AV entered the facility without being searched (which was against facility policy) and nearly pushed the SP down the stairs. The SP said that his/her actions were in self-defense and s/he was careful not to place the AV in a “choke hold.”

Although the SP said that s/he was defending him/herself and the AV had no physical injuries from the incident, the SP threatened to “fucking kill” the AV, punched the AV several times, held the AV on the floor with his/her arms wrapped around the AV’s head/chest and his/her legs wrapped around the AV’s torso/legs, and had continued verbal exchanges with the AV after the incident. The SP’s actions were not accidental and were not therapeutic conduct, posed a risk to the AV’s breathing, and represented a substantial risk of physical injury to the AV. Therefore, there was a preponderance of the evidence that physical abuse of the AV occurred.

It was determined that physical abuse occurred (“physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury).

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 facility’s policies and procedures, the Maltreatment of Minors Act, and was responsible for the care and supervision of the AV when the incident occurred. The SP was 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 abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain an injury from the incident.

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 which determined that its policies and procedures were adequate but were not followed. The SP’s employment at the facility was ended shortly after the incident and the facility provided additional training to other staff persons regarding Crisis Prevention Intervention, Resident Grievance Procedures, and de-escalation techniques.

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

The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the SP. The determination that the SP was 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.

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


state: MN

facility_name: Kadiri House LLC

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July 7, 2025

Stephen Williams, Authorized Agent

Kadiri House

2131 N 6th St., STE 2

Minneapolis, MN 55411

License Number: 1095378 (CRF)

Report Number: 202503071, 202503256, 202503334, 202503418, 202503461

CORRECTION ORDER

Dear Stephen:

On 5/13/2025 to 5/15/2025 a Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Kadiri House located at 2131 N 6th St., STE 2, Minneapolis, MN 55411. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, and children’s group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220. 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 failed to follow licensing rules and statutes, as described below.

Personnel

1. Violation: One of two personnel files reviewed for requirements governing orientation training (personnel file numbered 4) did not meet requirements. Documentation did not show that orientation to data practices regulations and issues was provided.

Rule Violated: Minnesota Rules, part 2960.0100, subpart 3, Item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation for requirements governing orientation training.

2. Violation: Four of four personnel files reviewed for requirements governing documentation of training (personnel file numbered 1, 2, 3, and 4) did not meet requirements. Documentation of training did not include the entity that provided the training.

Rule Violated: Minnesota Rules, part 2960.0100, subpart 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of orientation and ongoing training meets requirements. Within 30 days receipt of this correction order, submit training documentation that demonstrates compliance.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same Rule.

3. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet requirements in the following way:

I. Training on the program abuse prevention plan was completed late for the calendar year of 2024 (personnel file numbered 1) and was not completed for the calendar year of 2024 (personnel file numbered 2) and;

II. The emergency plan was not reviewed at least once every six months for the calendar year 2024 (personnel file numbered 1) and was not completed for the calendar year 2024 and 2025 up to the time of the review (personnel file numbered 2).

Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, part 2960.0080, subpart 14.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation for requirements governing ongoing training.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same statute and rule.

Residents

4. Violation: One of three resident files reviewed for requirements governing admission screenings did not meet requirements. The screening determined the resident was likely to have sexually abusive behaviors and there was no documentation to demonstrate a risk management plan was developed (resident file numbered 5).

Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, Items A and C.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation for requirements governing admission screenings.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same rule.

5. Violation: Two of two resident files reviewed for requirements governing no-eject discharges did not meet requirements in the following ways: There was no documentation for a resident who did not reach their case plan goals to show that requirements were met, in the following way:

I. There was no documentation to demonstrate the license holder conferred with other interested persons to review the issues involved in the decision (resident file numbered 4) and;

II. There was no documentation to demonstrate the license holder determined whether the treatment team and the resident could develop additional strategies to resolve the issues leading discharge (resident files numbered 3 and 4);

III. Documentation did not identify the reasons for the discharge and alternatives considered or attempted (resident file numbered 3 and 4).

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the provision and documentation for requirements governing discharge and aftercare. Within 30 days receipt of this correction order, submit documentation of a no-eject discharge that demonstrates compliance.

6. Violation: Two of two resident files reviewed for requirements governing transition services plans did not meet requirements. Documentation did not indicate that a copy of the plan was given to the resident, or any subsequent treatment providers (resident file numbered 1 and 2).

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, Item A.

Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the provision and documentation for requirements governing transition services plan. Within 30 days receipt of this correction order, submit a transition services plan that demonstrates compliance.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same rule.

7. Violation: Two of two resident files reviewed for requirements governing discharge documentation did not meet requirements in the following ways:

I. Documentation did not show how the facility met the goals and objectives identified in the treatment plan (resident file numbered 1) and;

II. Discharge documentation was not completed (resident file numbered 2).

Rule Violated: Minnesota Rules, part 2960.0140, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the documentation for requirements governing discharge. Within 30 days receipt of this correction order, submit discharge documentation for one resident that demonstrates compliance.

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.

Submissions required as part of the corrective action ordered must be sent to your licensor by email at elissa.olson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: LICENSOR

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 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 651-431-6276 or at elissa.olson@state.mn.us.

Sincerely,

Elissa Olson, Senior Licensor

MH/SUC/CRF 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


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June 11, 2025

Stephen W. Williams, Authorized Agent

Kadiri House

2907 Newton Avenue North

Minneapolis, MN 55411

License Number:   1095378 CRF

Investigation Report No.: 202410086

Dear Stephen W. Williams:

On April 24, 2025, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of the citation in the Correction Order issued to you by the Department of Human Services on April 21, 2025.

Violation: The license holder utilized a restrictive procedure with a resident and the license holder was not certified to use restrictive procedures.

An incident report dated November 20, 2024, documented that a staff person (SP1) utilized a restrictive procedure on resident (R1) by guiding R1 “to the ground.” Although documentation suggested the presence of imminent risk, the facility was not certified to utilize restrictive procedures, the license holder did not have a restrictive procedures plan approved by the commissioner, and staff persons were not trained on the use of physical holding.

Request for Reconsideration. You submitted a letter in which you indicated SP1’s actions were intended to be a spontaneous emergency intervention to prevent imminent harm to R1 rather than a restrictive procedure. You indicated SP1 acted in good faith under the facility’s general crisis response policy, which authorizes emergency de-escalation techniques and emphasizes client safety. You also stated the program had no pattern of using restrictive procedures and there was no plan or policy that permitted unauthorized restraint, and SP1 was trained in de-escalation, emergency interventions and maintaining client safety. You acknowledged that SP1 had not yet completed the certification process specific to restrictive procedures under Minnesota Rules, part 2960.0080.

Finally, you indicated immediate corrective action including additional training, policy review and implementation of additional safeguards was taken following the incident. You also noted that R1 had a known violent criminal history and had assaulted another staff member the previous day, and you noted that the program remains committed to providing safe, high-quality care to the residents. You referenced the incident report, updated training and policy documents, and an affidavit from a staff person, but those documents were not included with your reconsideration request.

Reconsideration Determination. Under Minnesota Rules, part 2960.0080, subpart 5, item E, the license holder must be certified to use restrictive procedures according to parts 2960.0710 to 2960.0750 before using a restrictive procedure wit a resident.

Under Minnesota Rules, part 2960.0020, subpart 63, item A, “restrictive procedure” means: for a facility licensed by the commissioner of human services, a procedure used by the license holder to limit the movement of a resident, including mechanical restraint, physical escort, physical holding and seclusion.

The incident report was reviewed and considered during the licensing investigation along with information about an additional incident involving R1. You acknowledged in the reconsideration request that the staff person had not yet completed the certification process specific to restrictive procedures, and the internal review indicates you acknowledged during the review that the program was not licensed for restrictive procedures. You also acknowledged during an interview with the DHS licensor that staff were not trained on restrictive procedures.

You indicated in the reconsideration request that SP1’s intent was to prevent imminent harm rather than to implement a restrictive procedure. However, information obtained during the licensing investigation indicated that while R1 was escalated and aggressive during the incident, SP1 had the option to walk away. You acknowledged that SP1 grabbed and physically held him/her, thereby restricting R1’s movement. SP1’s actions therefore met the definition of a restrictive procedure under the applicable rule.

Because the available information indicates a restrictive procedure was used when the license holder did not have certification to do so, there is sufficient evidence to support the citation.

Disposition: The Commissioner has reviewed your request for reconsideration and all the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the citation, and it is affirmed.

This is a final agency decision.

Sincerely,

Frances Simon Standing, Attorney

Legal Counsel’s Office

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/


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April 21, 2025

Stephen W. Williams, Authorized Agent

2907 Newton Ave. N.

Minneapolis, MN 55411

License Number: 1095378

Investigation Report Number: 202410086

CORRECTION ORDER

Dear Stephen Williams,

On February 6th, 2025, the Department of Human Services (DHS) conducted a licensing investigation regarding your facility, Kadiri House, located at 2907 Newton Ave. N. Minneapolis, MN 55411. This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120 and children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220. As a result of this investigation, 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 failed to follow licensing rules and statutes, as described below.

Violation: The license holder utilized a restrictive procedure with a resident and the license holder was not certified to use restrictive procedures.

An incident report dated November 20, 2024, documented that a staff person (SP1) utilized a restrictive procedure on a resident (R1) by guiding R1 “to the ground.” Documentation suggested the presence of imminent risk, however, the facility was not certified to utilize restrictive procedures, the license holder did not have a restrictive procedures plan approved by the commissioner, and staff persons were not trained on the use of physical holding.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item E.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the provisions governing restrictive procedures are not implemented at the program unless certification for the use is pursued.

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:

Commissioner, Department of Human Services

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

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960.

· 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 651-431-5909.

Sincerely,

Michael Cihla, 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/


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June 16, 2023

Stephen Williams, Authorized Agent

Kadiri House LLC

PO Box 7227

Denver, CO 80207

License Number: 1095378 (CRF)

CORRECTION ORDER

Dear Stephen Williams:

On March 13 through 15, 2023, a licensing review of Kadiri House located at 2131 North 6th St. Suite #2, Minneapolis, MN 55411, was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, and children’s group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220. As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder.

The following violations of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Postings, Policies, and Practices

1. Citation: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (d), and 2, paragraph (a).

Violation: The license holder failed to ensure postings met requirements. A copy of the program abuse prevention plan (PAPP) and the internal and external reporting policies and procedures for maltreatment were not posted in a prominent location in the facility.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program abuse prevention plan meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required.

2. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, parts 2960.0080, subparts 4, items A through C, and 5, and 2960.0160, subpart 4, item A.

Violation: The license holder failed to meet requirements pertaining to facility rules in the following ways:

a. Copies of the rules governing conduct and disciplinary consequences provided to the youth did not contain:

1. All of the rules implemented in practice by the license holder; and

2. The procedures for obtaining hygiene items; and

b. The facility rules did not include interventions used by the program. Room Restrictions and House Restrictions were identified interventions that were not described in policy.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the facility rules meet requirements.

3. Citation: Minnesota Rules, part 2960.0080, subpart 5.

Violation: The license holder utilized a disciplinary procedure/practice that is not permitted in DHS Licensed Children’s Residential Facilities. The disciplinary practice identified as Room Restriction required residents to remain in their room for multiple hours per day in response to an unacceptable behavior and/or safety measure.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all discipline and safety measures meets all applicable requirements. During the licensing review the license holder was ordered to immediately cease the practice of Room Restriction. Within 30 days receipt of this order, submit documentation demonstrating all staff have been trained on appropriate disciplinary measures used at the program.

4. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A.

Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not include the following required performance indicators:

a. Accidents;

b. The use of restrictive procedures;

c. Grievances;

d. Results from resident and family satisfaction surveys; and

e. Critical incidents

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements. Within 30 days receipt of this order, submit a template that includes the required performance indicators to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

5. Citation: Minnesota Rules, section 2960.0080, subpart 17, item A.

Violation: Eight of nineteen incident reports reviewed for requirements governing critical incident reports did not meet requirements. Critical incident reports were not submitted to DHS for the identified incidents:

a. A resident absconded and did not return within 24 hours (February 9, 2023, December 15, 2022, and November 3, 2022);

b. A staff person physically intervened with a resident, when the program was not certified for restrictive procedures, and emergency responders also intervened for one incident (December 28, 2022, November 12, 2022, October 27, 2022, and March 17, 2022); and

c. Emergency Responders intervened at the program (December 11, 2022).

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

Personnel Files

6. Citation: Minnesota Statutes, section 245A.041, subdivision 5.

Violation: Three of five personnel files reviewed for requirements governing documentation (personnel files numbered 1, 2, and 5) did not meet requirements. Documentation did not include the first date the staff person began working in a facility or setting.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements.

7. Citation: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0100, subpart 3, item A, and 2960.0150, subpart 4, item C.

Violation: One of three personnel files reviewed for requirements governing orientation training (personnel file numbered 5) did not meet requirements in the following ways:

a. The staff person was not oriented to the following:

1. Gender issues, including the psychosocial development of boys and girls;

2. Sexual orientation issues;

3. Physical, mental, sensory, and health-related disabilities, bias, and discrimination; and

4. Resident admission screens;

a. The staff person was not oriented to the following required topics before having unsupervised contact:

1. Emergency procedures;

2. Maltreatment of Minors reporting requirements under Minnesota Statutes, section 260E;

3. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues; and

4. General and special needs, including disability needs of residents and families served; and

b. The staff person was not oriented to the following required topics within 72 hours of first providing direct contact services:

1. Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572;

2. The program’s abuse prevention plan (PAPP); and

3. The program’s internal policies and procedures related to the prevention and reporting of maltreatment.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff person identified above has been trained to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

8. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: Three of three personnel files reviewed for the requirements governing medication assistance training (personnel files numbered 1, 2, and 4) did not meet requirements. There was no documentation to demonstrate the staff person received training on the program’s medication administration policies and procedures.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure medication assistance training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff persons identified above have been trained.

9. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D.

Violation: Four of four personnel files reviewed for the requirements governing the use of time-out training (personnel files numbered 1 through 4) did not meet requirements. The staff person was not trained prior to the use of time-out.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of training meets all applicable requirements.

10. Citation: Minnesota Rules, part, 2960.0100, subpart 5.

Violation: Four of five personnel files reviewed for requirements governing the documentation of training (personnel files numbered 1 through 3 and 5) did not meet requirements. The date, number of hours, and the name of the entity/person(s) providing the training was not documented to each topic area.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of training meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

11. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0080, subpart 14, 2960.0100, subparts 3 and 5, and 2960.0150, subpart 4, item D.

Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet requirements. There was no documentation to demonstrate the following training occurred:

a. The needs of residents and skills development (personnel file numbered 3);

b. Vulnerable adults maltreatment reporting requirements for the year 2022 (personnel files numbered 3 and 4);

c. The program abuse prevention plan (PAPP) and all internal policies and procedures related to the prevention and reporting of maltreatment for the year 2022 (personnel files numbered 3 and 4);

d. The emergency plan at least once every six months for calendar year 2022 (personnel files numbered 3 and 4); and

e. At least one hour of training for each 50 hours worked, for a part time staff person (personnel file numbered 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of ongoing training meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

Resident Files

12. Citation: Minnesota Rules, parts 2960.0070, subpart 4 and 2960.0090, subpart 3.

Violation: One of four resident files reviewed for requirements governing the inventory and handling of resident property did not meet requirements (resident file numbered 2). The resident’s property was not inventoried upon admission.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the inventory and handling of resident property meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

13. Citation: Minnesota Rules, parts 2960.0050, subparts 3, item A, and 4; 2960.0080, subpart 4; 2960.0160, subpart 4, item B

Violation: One of three resident files reviewed for requirements governing admission procedures (resident file numbered 1) did not meet requirements. The license holder failed to complete the following required procedures with the resident within 24 hours of admission:

a. Explain and provide a written copy of the resident’s basic rights; and

b. Provide a copy of the description of the applicable programs and activities available to the resident in the facility.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of admission procedures meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

14. Citation: Minnesota Statutes, section 245A.65, subdivisions 1, paragraphs (c) and 2, (a) and (b).

Violation: Two of two resident files reviewed for requirements governing vulnerable adult’s orientation and the individual abuse prevention plan (IAPP) did not meet requirements in the following ways:

a. There was no documentation to demonstrate the resident received orientation to the required policies and procedures governing the maltreatment of vulnerable adults for the following (resident files numbered 4 and 5):

1.   The internal and external reporting policies, including the telephone number for MAARC; and

2.   The program’s abuse prevention plan; and

b. An IAPP was not developed (resident file numbered 4); and

c. The IAPP did not include specific measures to be taken to minimize the risk of emotional abuse that was indicated (resident file numbered 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the vulnerable adult orientation and development of an IAPP for adult residents.

15. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A and C.

Violation: Three of three resident files reviewed for requirements governing admission screens did not meet requirements in the following ways:

a. The health screen did not occur within 24 hours of admission (resident file numbered 1);

b. The health screen did not include the address for the clinic identified (resident file numbered 2); and

c. A written risk management plan was not developed for a resident whose screening indicated that the resident was likely to have sexually abusive behavior (resident file numbered 2).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of admission screens meets all applicable requirements. Within 30 days receipt of this order, submit a Health Screen template that has been approved by a medical professional to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

16. Citation: Minnesota Statutes, section 245A.65, subdivisions 2, paragraph (b) and Minnesota Rules, part 2960.0180, subpart 2, item B.

Violation: Four of four resident files were reviewed for requirements governing treatment plans and service plan reviews did not meet requirements in the following ways:

a. There was no date on the treatment plan to demonstrate the development of the plan began within 10 days of admission (resident files numbered 1 through 3);

b. The treatment plan did not include individualized goals and a schedule for accomplishing goals and objectives (resident files numbered 1 and 3);

c. The individual abuse prevention plan (IAPP) was not reviewed as a part of the service plan review for July, September, and November 2022 (resident file numbered 5);

d. The treatment plan was not reviewed on a monthly basis for July and February 2022 (resident file numbered 1) and October 2022 (resident file numbered 3); and

e. Monthly review of treatment plans did not identify if changes were needed or recommended (resident files numbered 1 through 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plans and service plan reviews meet all applicable requirements. Within 30 days receipt of this order, submit a Treatment Plan and Treatment Plan Review for one resident to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

17. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D.

Violation: Three of five resident files reviewed for requirements governing time-out procedures did not meet requirements in the following ways:

a. Incident report documentation reviewed indicated a time-out was implemented on November 11, 2022 and February 13, 2023 (resident file numbered 1), December 28, 2022 (resident file numbered 7), and March 17, 2022 and February 13, 2023 (resident file numbered 8), and documentation did not include the following:

1. The factors or circumstances which caused the need for the use of time-out;

2. The resident's response to the time-out;

3. The resident's ability to de-escalate during the time-out procedure; and

4. The resident's ability to maintain acceptable behavior after the time-out.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of time-out meets all applicable requirements.

18. Citation: Minnesota Rules, part 2960.0080, subpart 11, items D and E.

Violation: Three of three resident files reviewed for requirements governing health care did not meet requirements in the following ways:

a. The medication verification form did not include the symptoms that the medication will alleviate (resident files numbered 1 and 2);

b. The medication administration record (MAR) did not include the amount of medication given, whether or not the resident received the medication, and the resident’s refusal to take medication for the following months:

1. July, August, September, and November 2022 and February 2023 (resident file numbered 1); and

2. November 2022 (resident file numbered 2);

c. The license holder did not document and follow the prescribing physician’s directions for monitoring medications in the following ways:

1. There were missing entries for blood sugar readings and use of diabetic supplies on the medication administration records (MAR) for September, November, and December 2022 (resident file numbered 3); and

2. MARs were not provided for review for the months of October 2022 (resident file numbered 2) and January and February 2023 (resident files numbered 2 and 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. Within 30 days receipt of this order, submit a MAR for one resident that meets requirements to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020.

19. Citation: Minnesota Rules, parts 2960.0190, subpart 1, item A.

Violation: One resident file reviewed for requirements governing transition services plans (resident file numbered 1) did not meet requirements in the following ways:

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

b. Resources available in the community were not identified for recreation, leisure, treatment services, and health services;

c. Recommendations for how the resident may deal with issues and potential challenges within the environment they were returning to were not provided; and

d. The plan was not developed with input from the resident and the resident’s family.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of discharge documentation meets all applicable requirements. Within 30 days receipt of this order, submit a revised template for a transition service plan to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 21, 2022.

If you fail to correct the violations 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.

Submissions required as part of a corrective action ordered must be sent to DHS Licensing at:

1. By secure email to: tina.christensen@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Tina Christensen, Human Services Senior Licensor

Licensing Division

Office of Inspector General

651-431-6610

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


facility_name: Lakeside Academy

report_date: January 30, 2026

raw_content:
January 30, 2026

Eric Vagle, Authorized Agent

Lakeside Academy

740 E 24th Street

Minneapolis, MN 55404-3862

License Number: 1078609 (CRF)

Report Number: 202504163

CORRECTION ORDER

Dear Eric Vagle:

On October 22 through 24, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Lakeside Academy located at 100 Garrison Avenue NE, Buffalo, MN 55313. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, (Rule CRF). 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.

Physical Plant

1. Violation: The license holder did not ensure that housekeeping and maintenance services were operated on a consistent and healthy basis to ensure the facility was kept in good repair. DHS licensors observed the following:

a. The main hall and bedroom walls and vents had handprints, graffiti, holes, dents, and food and other substances dried to them;

b. Windowsills contained built up dirt and leaves;

c. Two shower stalls were dirty;

d. Sprinkler heads in bedrooms were covered in spitballs;

e. A broken drawer in a bedroom dresser had sharp screws exposed (corrected on site); and

f. Items were hanging from exposed pipes in bedrooms.

Rule Violated: Minnesota Rules, part 2960.0110, subpart 3, item A, and 2960.0200, subpart Item A

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that housekeeping and maintenance is operated on a consistent and healthy basis to ensure the facility is kept in good repair. Within 30 days of receipt of this order, reach out to your assigned licensor to schedule a virtual tour to demonstrate compliance.

Policies, Procedures, and Practices

2. Violation: The license holder did not meet the needs of residents and ensure resident rights were protected in the following ways:

a. The license holder did not ensure the right to proactive adult guidance, support, and supervision was protected in a manner that would meet the needs of the residents. During a licensing investigation, DHS determined through review of resident files and program documentation, and resident and staff interviews, that a significant incident had occurred involving a physical altercation between residents that had lasted for more than ten minutes before a staff person intervened. On March 2, 2025, after a heightened verbal and physical conflict amongst four residents had occurred, two of those residents lured and pushed a third resident into a recreation room where the fourth resident was awaiting, and at which time the third and fourth resident engaged in a physical altercation that resulted in injuries to both residents; and

b. The license holder did not ensure the rights to reasonable communication and visitation with family, and unrestricted visitation with parents were protected, and that the policies were compatible with the needs of the residents. Review of policies and procedures, and interviews with residents and staff, during the on-site licensing review, determined the license holder’s Communication and Visitation policies, LASH 200 & 220, included the following:

i. Restrictions on the visiting rights of the parents of a resident beyond the limitations of those rights by a court order under Minnesota 260C.201, subdivision 5, or limitations in the resident's case plan;

ii. Restrictions on the allowance for communications with extended family members;

iii. An unreasonable allowance for communication with family, including parents; and

iv. The policies did not identify that the program will allow parental visits at times that accommodate the parent’s schedule.

Rule Violated: Minnesota Rules 2960.0050, subpart 1, items D and J; 2960.0150, subpart 3; and 2960.0080, Subpart 15, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the rights of residents are protected and the needs of the residents are met. Within 30 days of receipt of this order, submit a revised staffing plan and communication and visitation policy to demonstrate compliance.

3. Violation: The license holder did not develop and monitor the implementation of program policies and procedures as necessary to maintain compliance with licensing requirements under Minnesota Statutes and Rules, as accordingly for the following areas:

a. The license holder provides both children’s residential SUD services under MN Rules 2960 and is licensed to provide outpatient SUD services at the same location. The license holder’s indicated practice is to classify youth under the children’s residential facility license as either those receiving children’s residential SUD services or straight group residential who receive outpatient treatment services under 245G. The following policies and procedures did not identify this practice:

i. Statement of intended use;

ii. Admission policy; and

iii. Program Description;

b. The Maltreatment of Minors reporting policy did not reference current Minnesota Statutes, section 260E;

c. The written Grievance Procedure did not meet requirements. The license holder maintains two separate Grievance Procedures that are contradictory of each other; one within the policy and procedure manual, and the other within the student handbook;

d. The Plan for the Safe Storage and Delivery of medicine was not updated when the license’s holder practice to use a pharmacy to verify a newly admitted resident’s prescribed medications received approval;

e. The HIV Minimum Standards policy was not consistent with the current HIV Minimum Standards approved by the commissioner; and

f. The Spirituality Services policy (116) was not updated to the current practice within the program.

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, 14, paragraph (b); and 245A.19; and Minnesota Rules, parts 2960.0040, items B and D; 2960.0080, subparts 8, item A, 11, item D, 17, items B and D, and 18, item A; 2960.0160, subpart 1; and 2960.0180, subpart 2, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the policies identified above meet requirements. Within 30 days of receipt of this order, conduct a full review of the license holder’s policy and procedure manuals, revise applicable policies, and submit the revised policy and procedures identified above to demonstrate compliance.

4. Violation: The license holder’s admission policy did not include the following:

a. The staff who are authorized to discharge residents; and

b. A protocol for addressing the needs of individuals in need of emergency medical care not provided by the program and individuals who pose a substantial likelihood of harm to themselves or others, if the behavior is beyond the behavior management capabilities of the program and staff.

Rule Violated: Minnesota Rules, 2960.0480, subparts 1 and 2, item A.

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

5. Violation: The license holder’s Plan for Transfer Upon Closure did not meet requirements in the following ways:

a. The information on how clients would access their records was not identified;

b. The arrangements the program would make to transfer current clients and their records to another provider or county agency for the continuation of services were not identified; and

c. Annual reviews, including a signature, by a controlling individual of the program, were not completed for calendar years 2023 and 2024.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraphs (a) and (b)

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the Plan for Transfer Upon Closure meets requirements. Within 30 days of receipt of this order, submit a revised Plan for Transfer Upon Closure that demonstrates compliance.

6. Violation: The license holder’s Drug and Alcohol policy did not meet requirements. The policy identified specific types of chemicals, which are contradictory to statute, and it did not identify:

a. Subcontractors and volunteers; and

b. A chemical that impairs the individual’s ability to provide services or care.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 1, item C

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

7. Violation: The license holder’s Program Abuse Prevention Plan was not reviewed, at least annually, by the license holder’s governing body for calendar years 2023 and 2024.

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their annual review of the program abuse prevention plan meets requirements.

8. Violation: The license holder’s written schedule of daily activities did not describe the residents’

activities for each day of the week. The schedule did not include weekends.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 6.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the written schedule of daily activities meets requirements. Within 30 days of receipt of this order, submit a revised schedule of daily activities to demonstrate compliance.

9. Violation: The license holder did not develop a plan that offers appropriate recreation for residents.

Rule Violated: Minnesota Rules 2960.0080, subpart 10.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the development of a recreation plan for residents meets requirements. Within 30 days of receipt of this order, submit a plan that offers appropriate recreation for residents to demonstrate compliance.

10. Violation: The license holder did not document the provision of culturally appropriate care to each resident including the following:

a. Opportunities to associate with culturally and racially similar adults, peers, and role models;

b. Opportunities to participate in positive experiences related to the residents’ cultural and racial group; and

c. Efforts to contact a cultural or racial community group related to the resident’s cultural or racial minority background and seek information about how to provide opportunities for the resident to associate with adult and peer role models with similar backgrounds on a regular basis.

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 7, items A and B; and 2960.0100, subpart 2

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation for provision of culturally appropriate care to each resident meets requirements.

11. Violation: The license holder did not meet the requirements for program outcomes in the following ways:

a. The license holder’s written policy did not clearly identify their program outcomes;

b. The license holder did not annually evaluate the program’s strengths and weaknesses for calendar years 2023 and 2024, using the following performance indicators:

i. Accidents

ii. Grievances

iii. Results of a resident and family satisfaction survey

iv. The program’s outcomes and outcome measures; and

v. Critical incidents;

d. The license holder’s documentation did not demonstrate their use of the program evaluation reports and findings as a basis to make improvements in its program for calendar years 2023 and 2024; and

e. The license holder’s documentation did not demonstrate that at least annually the license holder met with community leaders representing the area where the facility is located to advise the community leaders about the nature of the program, the types of residents served, the results of the services the program provided to residents, the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months.

Rule Violated: Minnesota Rules, part 2960.0060, subparts 3, item A, 4, and 6.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of program outcomes and annual evaluation of strengths and weaknesses of the program meets requirements.

12. Violation: The license holder’s staff ratios did not meet requirements to ensure the minimum number of direct care staff that must be present and awake when residents are present and awake is one staff person per 12 residents for the following:

a. 1 staff to 18 residents from 4 to 6:30pm on 10/7/2025; and

b. 1 staff to 17 residents from 7 to 9am on 10/18/2025.

Rule Violated: Minnesota Rules, part 2960.0150, subpart 3, item G.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of staff ratios meet requirements.

13. Violation: The license holder did not meet critical incident reporting requirements in the following ways:

a. Incidents that occurred on the following dates met the definition of a critical incident and were not reported to DHS on September 20, 2024, January 12, 2025, March 2 and 6, 2025, and June 30, 2025; and

b. Critical incidents that occurred on the following dates were not reported to DHS within ten days: March 2, 2024, May 5 and 19, 2024, September 21, 2024, November 17, 2024, April 12, 2025, and July 7, 2025.

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

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

14. Violation: The license holder’s grievance practices did not meet requirements in the following ways:

a. The investigation findings and resulting action taken by the license holder were not documented grievances dated January 24, 2024, June 16 and 29, 2024, and June 1, 2025; and

b. The license holder did not follow their written grievance procedure for a grievance filed on May 17, 2025.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of grievance practices meets requirements.

15. Violation: The license holder’s satisfaction survey practices did not meet requirements. The license holder did not survey referring agencies regarding the license holder’s satisfaction with the services.

Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of satisfaction survey practices meets requirements.

Personnel Files

16. Violation: Three of twelve personnel files reviewed for requirements governing background study documentation in a children’s residential facility did not meet requirements. The license holder did not document:

a. The first date that a staff person began working in the license holder’s facility (personnel file numbered 1); and

b. The first date that a staff person had direct contact, as defined in section 245C.02, subdivision 11, with a person served by the license holder’s program (personnel files numbered 1, 2, and 4).

Statute Violated: Minnesota Statutes, sections 245A.041, subdivisions 5 and 6.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of the documentation of background studies meets all applicable requirements.

17. Violation: The license holder did not meet requirements governing the supervision of individuals with a temporary permit from the Board of Behavioral Health and Therapy (personnel file numbered 2). The individual was supervised by a Licensed Alcohol and Drug Counselor assigned by the license holder who also was qualified as a clinical supervisor approved by the Board of Behavioral Health and Therapy; however, the supervision documentation did not demonstrate either of the following:

a. Weekly supervision, related to clinical practices, had occurred, and the documentation included the amount and type of supervision; or

b. Supervision had occurred and met the requirements of Minnesota Statutes, section 148F.04, subdivision 4.

Rule Violated: Minnesota Rules, part2960.0460, subpart 6a.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of supervision for an individual with a temporary permit meets all applicable requirements.

18. Violation: Five of twelve personnel files reviewed for requirements governing staff qualifications did not meet requirements in the following ways:

a. Documentation did not demonstrate that the staff had been trained in gender-based needs and issues (personnel file numbered 7); and

b. The personnel file of an alcohol and drug counselor did not include documentation to demonstrate that the individual had the following:

i. An additional 30 hours of classroom instruction in adolescent development (personnel files numbered 1, 2, and 4);

ii. At least 150 hours of supervised experience as an adolescent alcohol and drug counselor, either as a student or as an employee (personnel file numbered 1); and

iii. Current professional licensure (personnel file numbered 9).

Rule Violated: Minnesota Rules, parts 2960.0100, subpart 6, item B; 2960.0150, subpart 2; 2960.0460, subparts 5, items B and C.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff qualifications meets all applicable requirements.

19. Violation: Eight of nine personnel files reviewed governing orientation training did not meet requirements in the following ways:

a. Documentation did not demonstrate that the staff persons and student intern received orientation to the following topics before having unsupervised contact with residents:

i. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment (personnel files numbered 2, 5, and 7);

ii. Maltreatment of Minors reporting requirements under Minnesota Statutes, sections 260E (personnel files numbered 1, 2, 4, 5, and 7);

iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 5, 7, and 10);

iv. General and special needs, including disability needs or residents and families served (personnel files numbered 1, 2, 4, 5, 7, and 10);

v. Operational policies and procedures (personnel file numbered 5); and

vi. Data practices regulations and issues (personnel files numbered 1, 2, 5, and 7);

b. Documentation did not demonstrate that within 72 hours of first providing direct contact services, the staff persons and student intern were oriented to the following:

i. Vulnerable adults maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 1, 2, and 7);

ii. The license holder’s program abuse prevention plan (personnel file numbered 7);

iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1, 2, 3, and 7); and

iv. HIV Minimum Standards (personnel files numbered 1, 2, and 7);

c. Training on the administration of screenings upon admission of residents was not provided for a staff person who was responsible to administer (personnel files numbered 1, 2, and 4);

d. Employees and volunteers were not trained on the program’s drug and alcohol policy before the individuals had direct contact with persons served by the program (personnel files numbered 6 and 7);

e. There was no documentation to demonstrate that the license holder provided a volunteer orientation and training on the following topics (personnel file numbered 6):

i. Culturally competent care;

ii. Racial bias and racism issues;

iii. Gender issues;

iv. Sexual orientation issues;

v. Physical, mental, sensory, and health-related disabilities, bias, and discrimination; and

vi. The program, its purpose, and the population served;

f. There was no documentation to demonstrate that the license holder obtained, in writing, a volunteer’s agreement to abide the facility’s policies (personnel file numbered 6); and

g. Training documentation did not include the name of the entity/person(s) that provided the training (personnel files numbered 1, 2, 4 through 7, 9, and 10).

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 1, 245A.19, and 245A.65, subdivision 3; Minnesota Rules 2960.0070, subpart 5; 2960.0080, subpart 11; 2960.0100, subparts 3 and 5; 2960.0150 subparts 3, 4, and 5; 2960.0450, subparts 5 and 9.

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

20. Violation: Six of six personnel files reviewed governing ongoing training did not meet requirements in the following ways (personnel files numbered 2, 3, 8, 9, 11, and 12):

a. Documentation did not demonstrate the staff person received ongoing training to:

i. Maltreatment of minors reporting requirements and definitions in Chapter 260E.06 subd 1; and

ii. HIV Minimum Standards, annually; and

b. Training documentation did not include the name of the entity/person(s) that provided the training.

Statute and Rule Violated: Minnesota Statutes, sections 245A.66, subdivision 4; Minnesota Rules 2960.0100, subpart 5.

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

Resident Files

21. Violation: One of three resident files reviewed for requirements governing admission procedures (resident file numbered 2) did not meet requirements. The license holder did not inventory the resident’s personal property, including clothing.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of admission procedures meet all applicable requirements.

22. Violation: Three of three resident files reviewed for requirements governing admission screenings (resident files numbered 1 through 3) did not meet requirements in the following ways:

a. The screening for sexually abusive behavior was not completed;

b. The screening instrument used did not include all components required by the cultural screening tool approved by the commissioner;

c. The screening to determine the resident’s gender-based needs was not completed; and

d. There were no documented inquiries and results of the inquiries regarding the degree to which the resident’s family desired to be involved during the resident’s stay in the facility.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items A through D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of admission screening meets all applicable requirements. Within 30 days of receipt of this order, submit screening documentation for one resident that demonstrates compliance.

23. Violation: One resident file reviewed for requirements governing program services (resident file numbered 1) did not meet requirements. The license holder did not review the emergency plan with the resident at least every six months.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 14.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of program services meets all applicable requirements.

24. Violation: One of three resident files reviewed for requirements governing treatment plans (resident file numbered 3) did not meet requirements. The license holder did not begin to develop a treatment plan within 10 days of admission.

Rule Violated: Minnesota Rules, part 2960.0180, subpart 2, item (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of treatment plans meets all applicable requirements.

25. Violation: Three of three resident files reviewed for requirements governing required treatment services and documentation did not meet requirements. The license holder did not document the amount of each service the resident had received weekly into the residents’ files for the following weeks reviewed:

a. January 12 through 18, 2025, and March 16 through 22, 2025 (resident file numbered 1);

b. June 8 through 14, 2025, and September 14 through 20, 2025 (resident file numbered 2); and

c. January 19 through 25, 2025, and February 9 through 15, 2025 (resident file numbered 3).

Rule Violated: Minnesota Rules, part 2960.0490, subpart 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of required treatment services meets all applicable requirements. Within 30 days of receipt of this order, submit a resident file that demonstrates compliance.

26. Violation: Three of three resident files reviewed for requirements governing the administration of medications (resident files numbered 1 through 3) did not meet requirements. The license holder did not:

a. Contact a newly admitted residents’ prescribing medically licensed person to verify the symptoms the medication would alleviate and the symptoms that would warrant a consultation with the physician (resident files numbered 1 through 3);

b. Document attempts to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident files numbered 1 through 3);

c. Document and follow the prescribing physician’s directions for administering a medication used by the resident for a medication started on February 21, 2025 (resident file numbered 3); and

d. Keep records for a resident who received prescription drugs at the facility and note the quantity initially received from the pharmacy (resident files numbered 1 and 2).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D and E.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of health care meets all applicable requirements. Within 30 days of receipt of this order, submit medication verification documentation for one resident that demonstrates compliance.

27. Violation: One of two resident files reviewed for requirements governing no eject (resident file numbered 3) did not meet requirements in the following ways:

a. Documentation did not demonstrate that before the license holder discharged a resident who had not yet reached their treatment plan goals, the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge and permit the resident an opportunity to continue to receive services;

b. The license holder exceeded the five allowable working days to complete the review process; and

c. Documentation of the reasons that warranted discharge was inconsistent. The license holder maintained two discharge summaries, one completed upon discharge, the other modified months later, and the information included in each was not consistent.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

Repeat Violation: The license holder was previously found in violation of the same rule in a correction order DHS issued on July 2, 2021.

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

28. Violation: Two of two resident files reviewed for requirements governing transition services plan (resident files numbered 4 and 5) did not meet requirements in the following ways:

a. The license holder did not develop a plan with input from the resident, the resident’s family members, if appropriate, the providing school district, and the persons who will provide support services to the resident upon release;

b. The license holder did not document providing a copy of the plan to the resident or to the residential treatment facility that the resident would attend or was placed at after release; and

c. The transitional services plan did not include the following:

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

ii. Health services; and

iii. Personal safety needs.

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 all applicable requirements. Within 30 days of receipt of this order, submit a transition services plan for one resident that demonstrates compliance.

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.

Submissions required as part of the corrective action ordered must be sent to your licensor by email at alyssa.nelson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Alyssa Nelson

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 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: January 2, 2026

raw_content:
January 2, 2026                   CERTIFIED MAIL

Eric Vagel, Authorized Agent

Lakeside Academy

740 E. 24th St.

Minneapolis, MN 55404

License Number 1078609 (CRF)

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATIONS

Dear Eric Vagel:

The Department of Human Services (DHS) is ordering you to pay a fine of $800 for four background study violations. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order based on your failure to comply with the following background study requirements:

Background Study Violation Determined on October 22, 2025:

1. As a result of a licensing review, a DHS Licensor determined that you failed to initiate a background study request for two staff persons (SP2 and SP4) after being ordered to do so by DHS.

On October 22, 2025, DHS determined SP2 and SP4 did not have a valid background study. Fingerprint studies were not submitted after the COVID studies had expired on December 31, 2022.

Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraphs (a) and (b).

Fine: $400

Corrective Action Required: You must comply with background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit documentation demonstrating that background studies have been submitted and that the program has received notice to allow the identified staff persons above, to work in the children’s residential facility.

2. As a result of a licensing review on October 22, 2025, a DHS Licensor determined that the license holder allowed individuals (SP1 and SP3) to work in the children’s residential facility prior to receipt of notice.

a. SP1 was hired and began working in the facility on April 28, 2022, however, the license holder did not receive notice until May 1, 2022; and

b. SP3 was hired and began working in the facility on July 23, 2025, however, the license holder did not receive notice until August 4, 2025.

Statute Violated: Minnesota Statutes, sections 245C.11 and 245C.13, subdivision 2, paragraphs (a) and (c).

Fine: $400

Corrective Action Required: You must comply with background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance will be maintained in the future.

Billing and Payment of the Fine

DHS will send you an invoice for the $800 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 are jointly 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.

Your Right to Appeal

You have the right to 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 receive this order. Please send it to:

Commissioner, Department of Human Services

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 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

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

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.lawhelpmn.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

· DHS may impose a $200 fine for each background study violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

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

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(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)(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.

· 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.

· NetStudy 2.0 is defined by Minnesota Statutes, section 245C.02, subdivision 13e.

Questions

If you have any further questions regarding this matter, you may contact Paula Halverson, Unit Manager, at 651-431-5653.

Sincerely,

Paula Halverson, Unit Manager

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: Notice of Violation