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September 12, 2025 RE: Oakley Care Inc. License Number: 1108406 (245D HCBS)
Yasin Siyad, Authorized Agent Oakley Care, Inc. 6109 Blue Circle Drive Suite 1000 Hopkins, Minnesota 55343 Dear Yasin Siyad: This matter arises from an Order of Conditional License (“Conditional Order”) issued to Oakley Care, Inc. (“Oakley,” “license holder,” or “you”) dated May 13, 2025. On June 20, 2025, the Minnesota Department of Human Services (DHS), Licensing Division, received the license holder’s request for reconsideration of the decision to place the license holder’s license on conditional status. The license holder also requested reconsideration of Citation 16, but did not specifically challenge any of the other citations listed in the Conditional Order. DHS’ response is addressed below: A. RECONSIDERATION OF CONDITIONAL LICENSE Citation 16 You challenged Citation 16 of the Conditional Order. DHS issued the violation because you did not prohibit the use of manual restraints and seclusion in P7, P8, and P9’s positive support transition plans (PSTP). A person’s protection-related rights include the right to be free from restraint, time out, seclusion, restrictive intervention, or other prohibited procedures identified in section 245D.06, subdivision 5. Minnesota Statutes, section 245D.04, subdivision 3. License holders are required to remove any existing plans for the emergency or programmatic use of restrictive interventions from the PSTPs. Minnesota Statutes, section 245D.06, subdivision 8. On reconsideration you state you did not use prohibited procedures in the program. You state you inadvertently included references to manual restraints and seclusion in the PSTPs because you were using an outdated DHS form. In your reconsideration request you acknowledge that you included manual restraints and seclusion in the PSTPs. For example, P7’s PSTP stated, “Emergency Use of manual restraint”… “Per Oakley Care guidelines, emergency use of manual restraint will be used to separate [P7] if [s/he] tries to hurt anyone in the community or hurt [him/herself].” Since the law requires that you prohibit the use of prohibited procedures in the clients’ PSTP and you did not do so, this citation was correct, and it is affirmed. Other arguments in the reconsideration request: First, the license holder contends the licensing reviews were in December 2024 and January 2025, but that Oakley was not issued a Correction Order for those reviews. The license holder is correct in that DHS did not issue a Correction Order for the violations determined during the December 3-4, 2024, and January 13, 2025, licensing reviews. The violations determined at the December 3-4, 2024, and January 13, 2025, reviews are included in the Order, as explained on page 1 of the Order. Second, the license holder states the violations from a May 21, 2024, Correction Order cannot be used to show repeat violations because the license holder did not have notice of the violations from the December 2024 and January 2025, licensing reviews or have a chance to respond to them. The violations in the May 21, 2024, Correction Order are conclusive because the license holder did not request reconsideration. Under Minnesota Statutes, section 245A.06, subdivision 4, license holders have the right to request reconsideration of the new violations in the Conditional Order, as described in the Order. If there is insufficient evidence to support the citations, the citation will be rescinded, and it will not be a repeat violation. Here, you only requested reconsideration of Citation 16, and it was affirmed. You did not challenge Citations 1 through 15 and 17, and those violations are now final. Therefore, there is a basis for the repeat violations. Third, the license holder argues that DHS cannot credibly claim it is concerned about the license holder’s program operation and ability to demonstrate competent knowledge given there was significant improvement at a March 2025, licensing review, that only resulted in two violations. In March 2025, DHS did not conduct a licensing review. Instead, DHS maltreatment investigators conducted a maltreatment investigation to investigate a specific allegation of maltreatment. Since it was not a licensing review, DHS did not conduct a comprehensive evaluation of the program to determine compliance with laws and rules. Therefore, it is inaccurate to state that the two citations show the program improved from the time of the May 21, 2024, Correction Order. Rather, at the next licensing reviews that DHS conducted about six months later in December 2024 and January 2025, DHS determined the program was responsible for 17 violations. This demonstrates that the program did not improve. Fourth, the license holder contends the violations in the May 2024 and May 2025 Correction Orders were largely based on policy and procedure violations with no findings that any client was harmed or that there was a risk of harm. As stated above, these two Correction Orders are conclusive and cannot now be refuted. Minnesota Statues The risk of harm to the persons served will be discussed below. B. A conditional license is warranted The Commissioner determined that it was appropriate to place the license holder’s license on conditional status based on the nature, severity, and chronicity of the violations as well as Commissioner’s evaluation of the program. Nature, severity, or chronicity Under Minnesota Statutes, section 245A.06, subdivision 1, the Commissioner must consider the nature, severity, or chronicity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program when issuing a conditional license. The nature and severity of the violations and the effect of the violations on the persons served, warrant the conditional license. The continued violations after DHS issued Correction Orders shows you did not hire a competent Designated Manager and Designated Coordinator. As a result of your failure to hire a qualified and competent Designated Coordinator and Designated Manager and your lack of knowledge of laws and rules, you were found in violation of 13 violations in the May 21, 2024, Correction Order, two citations in the May 26, 2025, Correction Order, and the seventeen citations in the Conditional Order. Based on the importance of these two roles and the numerous and repeated citations, this is a serious violation. Many of the violations involve your failure to properly administer medications, which could affect the health and safety of the service recipients. You also did not report a serious injury and a possible incident of maltreatment to the DHS when a vulnerable adult was struck by a vehicle in an attempted suicide. In addition, your program allowed prohibited procedures, which included seclusion and the use of manual restraints for three vulnerable adults whose records were reviewed. Regarding chronicity, DHS issued a May 21, 2024, Correction Order to you that included 13 violations and a Conditional license that included 17 violations. Seven of the violations in the Conditional License Order were repeat violations showing you did not remedy the violations after notice from DHS. Based on this recent history of significant noncompliance, on the number and serious nature of the violations in the Conditional Order, and that you demonstrated a lack of understanding of the law, the Commissioner believes the program can benefit from additional oversight to ensure it can gain and continue compliance with licensing regulations. C. CONDITIONAL LICENSE TERMS The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, in addition to or other than SP5 who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, in addition to or other than SP5, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the persons who will fulfill the duties and responsibilities of your designated coordinator and designated manager for DHS review and approval. It is your responsibility to ensure that these persons meet the necessary qualifications. You must maintain documentation of your designated coordinator and designated manager’s qualifications in their personnel records and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 30 days of receiving this order, you must submit a written plan to DHS detailing how you will: · ensure the corrective action ordered in this order is completed; and · audit all persons served and staff records for compliance with all applicable rules and statutes. The written plans must detail the roles and responsibilities that your designated coordinator and designated manager will have in completing corrective action and auditing all persons served and staff records. 4. Within 60 days of receiving this order, you must: · complete an audit of all person served and personnel records according to your written plan. The audit must be completed by your designated coordinator and/or designated manager; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · submit the date to your DHS licensor that all person served and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order. 5. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 6. You may not add additional services to this license for the duration of the conditional license. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at kristopher.oberg@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Kristopher Oberg Licensing Division PO Box 64242 St. Paul, MN 55164-0242 D. RIGHT TO APPEAL TO THE MINNESOTA COURT OF APPEALS This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, please contact Christala Culhane, Unit Manager, at 651-431-6581. Sincerely,
Kofi Montzka, Attorney Legal Counsel’s Office Office of Inspector General
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