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June 20, 2023 Ebony Warren, Authorized Agent Evergreen Shelter Program
License Number: 800759 (CRF) CORRECTION ORDER Dear Ebony Warren:  On May 22, 2023, DHS Licensing conducted a full licensing review at your facility, Evergreen Shelter Program, located at . As a result of this visit, DHS is issuing this order which requires you to take the corrective 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 FILES 1. Violation: One of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 1). Documentation of orientation for operational policies and procedures of the license holder, including the program’s drug and alcohol policy, was left blank. Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c), and Minnesota Rules, part 2960.00100, subpart 3, item A Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation documentation meets all applicable requirements. 2. Violation: Two of two personnel files reviewed for requirements governing the provision of ongoing staff training did not meet requirements (personnel files numbered 1 and 3). Documentation did not show that the emergency plan was reviewed every 6 months in the year 2022. Rule Violated: 2960.0080, Subpart 14 Repeat Violation: In a Correction Order that DHS issued on December 9, 2020, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. RESIDENT FILES 3. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 2, and 3). There was no date on the “Client Inventory” document to demonstrate that it was completed upon admission. Rule Violated: 2960.0070, Subpart 4 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that inventory and handling of resident property meet all applicable requirements. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: 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 651-431-6259. Sincerely, Katie Leuer, Unit Supervisor Licensing Division Office of Inspector General
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