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November 10, 2025 Debesay Girmalul, Authorized Agent Comfort Adult Daycare LLC 1201 37th Avenue North License Number: 1092616 (Rule 223) CORRECTION ORDER Dear Debesay Girmalul: On July 8, 2025, a licensing review of Comfort Adult Daycare LLC located at 1821 University Avenue West, Saint Paul, Minnesota, was conducted to determine compliance with Minnesota Statutes and Rules governing adult day care services under Minnesota Rules, parts 9555.9600 through 9555.9730 (Rule 223). 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 the 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 license holder. The following violation(s) 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. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For one of four participants whose record was reviewed (P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan (PAPP) as required. The license holder did not provide P2 orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the PAPP within 24 hours of admission. Repeat Violation: In a Correction Order that DHS issued on April 29, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, you must provide P2 an orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and PAPP. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P1-P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder did not review P1’s IAPPs quarterly as part of the review of the program plan or service plan. b. The license holder did not develop an IAPP for P2 as part of P2’s initial individual program plan or service plan. c. The license holder did not review P3 and P4’s IAPPs with their interdisciplinary team, at least annually in 2025, using the individual assessment and any reports of abuse relating to the person. The most recent review of P3’s IAPP was dated June 14, 2024. The most recent review of P4’s IAPP was dated May 14, 2024. Repeat Violation: In a Correction Order that DHS issued on April 29, 2025, you were previously found in violation of this same statute and rule. Corrective Action Ordered: Within 15 days of receiving this order, you must develop an IAPP for P2. Within 30 days of receiving this order, you must: · review P1’s IAPP quarterly as part of the review of the program plan or service plan; and · review P3 and P4’s IAPPs with their interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision and rule. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not include information in the participant’s written record as required. a. The license holder did not maintain participation reports and progress notes that were recorded at least monthly in P1’s participant record. b. The license holder did not include the following information in P2’s participant record: · a medical report, dated within the three months prior to or 30 days after P2’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that included: o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · participation reports and progress notes that are recorded at least monthly. c. The license holder did not maintain a medical report in P3’s record that was updated annually in 2025.
Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P1-P3’s participant records. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For one participant whose record was reviewed (P2), the license holder did not complete initial service planning as required. The license holder did not: · conduct a needs assessment for P2 within 30 days of P2’s admission to the center that included: o P2’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); o P2’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and o P2's physical status, determined by observation, from the intake screening interview, and from the medical report received from P2's physician. · develop a preliminary service plan for P2 that included: o scheduled days of P2’s attendance at the center; o transportation arrangements for getting P2 to and from the center; o P2’s nutritional needs and where applicable, dietary restrictions; o the role of P2’s caregiver or caregivers in carrying out the service plan; and o services and activities in which P2 will take part in immediately upon admission.
Corrective Action Ordered: Within 30 days of receiving this order, you must develop a needs assessment and preliminary service plan for P2 that includes the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P1-P4), the license holder did not develop a written plan of care as required. a. The license holder did not develop a written plan of care for P2 within 90 days of admission to the center that included: · an update of the preliminary service plan and additional services required by P2; · short and long term objectives for P2 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · the anticipated duration of the individual plan of care as written. b. The license holder did not develop a written plan of care for P1, P3, and P4 that included provisions for quarterly reviews and quarterly revisions of the individual plan of care. Repeat Violation: In a Correction Order that DHS issued on April 29, 2025, you were previously found in violation of this same rule. 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. 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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. Alexandra Devick, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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