March 4, 2026

Maika Moua, Authorized Agent

Asian Community Center LLC
710 Arcade Street
Saint Paul, Minnesota, 55106

License Number: 1063125 (Rule 223)

CORRECTION ORDER

Dear Maika Moua:

On January 7, 2026, a licensing review of Asian Community Center LLC located at 710 Arcade Street, 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.14, subdivision 14, paragraph (c).

Violation: The license holder did not meet the requirements for attendance record documentation.

The license holder did not maintain documentation of actual attendance for each adult day service recipient for which the license holder for which the license holder was reimbursed by a governmental program that included:

· the time of day that the recipient was dropped off; and

· the time of day that the recipient was picked up.

Repeat Violation: In a Correction Order that DHS issued on October 6, 2023, you were previously found in violation of this same statute.

Corrective Action Ordered: Immediately, you must maintain documentation of actual attendance for each adult day service recipient. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a).

Violation: For one of three 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.

P2 was readmitted to the center on January 8, 2024; however, the license holder did not provide orientation to P2 on the license holder’s internal and external reporting procedures and PAPP with 24 hours of admission.

Corrective Action Ordered: Immediately, you must:

· provide an orientation to P2 and P2’s legal representative on the license holder’s internal and external reporting procedures and PAPP; and

· document that P2 and P2’s legal representative was provided the orientation in P2’s record.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subdivisions.

3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3.

Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP).

a. The license holder did not review P1 and P2’s IAPP with P1 and P2’s interdisciplinary team, at least annually, using the individual assessment and any reports of abuse relating to the person.

b. The license holder did not review P2’s IAPP quarterly as part of the review of the program plan or service plan.

c. The license holder did not develop an IAPP for P3 as part of P3’s initial individual program plan or service plan that included:

· an individualized assessment of P3’s susceptibility to abuse by other individuals, including other vulnerable adults;

· P3’s risk of abusing other vulnerable adults; and

· statements of the specific measures to be taken to minimize the risk of abuse to P3 and other vulnerable adults.

Repeat Violation: In a Correction Order that DHS issued on October 6, 2023, you were previously found in violation of this same rule.

Corrective Action Ordered: Within 15 days of receiving this order, you must develop an IAPP for P3. Within 30 days of receiving this order, you must:

· review P2’s IAPP quarterly as part of the review of the program plan or service plan and document the review and date the review occurred;

· review P1 and P2’s IAPP annually with P1 and P2’s interdisciplinary teams and document the review;

· complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and

· for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision and subpart.

4. Citation: Minnesota Rules, part 9555.9640.

Violation: For one participant whose record was reviewed (P2), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required.

P2 was readmitted to the center on January 8, 2024. The license holder did not distribute the following policies and program information to P2 and P2’s caregivers:

· the scope of the programs, services, and care offered by the center;

· a description of the population to be served by the center;

· a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering;

· the center's policy on and arrangements for providing transportation;

· the center's policy on providing meals and snacks;

· the center's fees, billing arrangements, and plans for payment;

· the center's policy governing the presence of pets in the center;

· the center's policy on smoking in the center;

· types of insurance coverage carried by the center;

· a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section;

· a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act;

· the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and

· the telephone number of the department's licensing division.

Corrective Action Ordered: Immediately, you must:

· distribute the policies and program information listed above to P2 and their caregivers; and

· document the distribution of the policies and program information in P2’s record.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part.

5. Citation: Minnesota Rules, part 9555.9660, subpart 1.

Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not include information in the participant’s written record as required.

a. The license holder did not include the following information in P1’s participant record:

· an application form that included P1’s source of referral and the name and telephone number of a secondary person to call in case of an emergency involving P1;

· a medical report dated within the three months prior to or 30 days after P1’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 report a report on a physical examination, updated annually;

o medical history for P1;

o indication of dietary restrictions and medication regimen, including the need for medication assistance that apply to P1;

o a release signed by the physician indicating whether P1 can engage in a structured exercise program; and

o documentation that P1 is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants.

· participation reports and progress notes that are recorded at least monthly.

b. The license holder did not include the following information in P2’s participant record:

· an application form that included P2’s living arrangement and source of referral; and

· a medical report that was 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 report on a physical examination, updated annually;

o medical history for P2;

o indication of dietary restrictions and medication regimen, including the need for medication assistance that apply to P2;

o a release signed by the physician indicating whether P2 can engage in a structured exercise program; and

o documentation that P2 is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants.

c. The license holder did not include the following information in P3’s participant record:

· a report on a physical examination, updated annually; and

· participation reports and progress notes that are recorded at least monthly.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information for P1, P2, and P3 as detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

6. Citation: Minnesota Rules, part 9555.9700, subpart 2.

Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not complete initial service planning as required.

a. The license holder did not develop a preliminary service plan for P1 that included:

· the role of P1’s caregiver or caregivers in carrying out the service plan; and

· services and activities in which P1 will take part immediately upon admission.

b. 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 P1 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, when applicable, dietary restrictions;

o role of P2’s caregiver or caregivers in carrying out the service plan; and

o services and activities in which P2 will take part immediately upon admission.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· develop a need assessment for P2 that includes the information detailed above;

· develop a preliminary service plan for P1 and P2 that includes the information detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

7. Citation: Minnesota Rules, part 9555.9700, subpart 3.

Violation: For three participants whose records were reviewed (P1, P2, and P3), 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 P1 that include:

· an update of the preliminary service plan and additional service required by P1;

· short and long-term objectives for P1 stated in concrete, measurable, and time specific outcomes;

· the anticipated duration of the individual plan of care as written; and

· provisions for quarterly reviews and quarterly revision of the individual plan of care.

b. The license holder did not develop a written plan of car for P2 that include:

· an update to the preliminary service plan and additional service required by P2;

· short and long-term objective for P2 stated in concrete, measurable, and time specific outcomes; and

· the anticipated duration of the individual plan of care as written.

c. The license holder did not develop a written plan of care for P3 that included:

· an update of the preliminary service plan and additional services required by P3;

· short and long-term objectives for P3 stated in concrete, measurable, and time specific outcomes;

· the staff members responsible for implementing the individual plan of care;

· the anticipated duration of the individual plan of care as written; and

· provisions for quarterly reviews and quarterly revisions of the individual plan of care.

Corrective Action Ordered: Within 30 days of receiving this order, you must develop a written plan of care for P1, P2, and P3 that includes the information detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

8. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review to a mandated reporter as required.

The license holder did not provide SP1 and SP2 annual review to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder’s PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required training to a mandated reporter as detailed above to SP1 and SP2. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

9. Citation: Minnesota Rules, part 9555.9690, subpart 4.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required.

The license holder did not provide SP1 and SP2 eight hours of in-service training annually in 2025 that included:

· areas related to care of persons;

· including provision of medication assistance; and

· review of parts 9555.9600 to 9555.9730.

Repeat Violation: In a Correction Order that DHS issued on October 6, 2023, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service annual training detailed above to SP1 and SP2. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

10. Citation: Minnesota Rules, part 9555.9710, subparts 3 and 7.

Violation: The license holder did not offer services as required.

a. The license holder did not provide consultation and review of health services at least monthly that included:

· monitoring the participants health status and reporting changes to the participants’ caregiver, physician, and center director;

· educating and counseling participants on good health practices;

· maintain a listing of professional health resources available for referrals as needed by people;

· developing policies and monitoring procedures for participants’ self-administration of medications for training unlicensed personnel who provide medication assistance; and

· supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 1, item C.

b. The license holder did not maintain a family and social history in P3’s record that was updated annually.

Repeat Violation: In a Correction Order that DHS issued on October 6, 2023, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide services as detailed above. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts.

11. Citation: Minnesota Rules, part 9555.9720, subparts 7, 8, and 9.

Violation: The license holder did not ensure safety as required.

a. The license holder did not ensure equipment and furniture was in good repair, including:

· torn and snagged carpet with significant stains;

· crumbling and broken floor tiles in the bathrooms, and

· water damaged ceiling tiles.

b. The license holder did not ensure areas used by participants receiving services were free from loose plaster and peeling paint.

c. The license holder did not ensure the written plans for emergencies caused by fire and weather included:

· identification of an emergency shelter area within the center;

· procedures for the quarterly fire drill; and

· the location and use of fire extinguishers.

d. The license holder did not ensure the fire escape plan was rehearsed at least four times a year.

Repeat Violation: In a Correction Order that DHS issued on October 6, 2023, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receiving this order, you must ensure safety as detailed above. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts.

12. Citation: Minnesota Rules, part 9555.9730, subpart 3.

Violation: The license holder did not ensure physical and space requirements.

The license holder did not ensure restrooms used by participants were equipped with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance.  

Corrective Action Required: Immediately, you must ensure restrooms used by participants are equipped with a mechanism that participants could use to signal staff members by light or by sound if participants need assistance. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

13. Citation: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (b.)

Violation: The license holder did not notify the commissioner before making any change to the license holder’s controlling individuals as required.

The license holder did not notify the commissioner of the addition of controlling individual (SP4) that occurred on January 1, 2018, and the removal of (SP3) that occurred on March 1, 2024, the license holder had not notified the commissioner of this change in the manner prescribed by the commissioner.

Corrective Action Ordered: Within 10 days of receiving this order, you must contact your licensor to initiate and complete the request to update controlling individual. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

14. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and section 626.557, subdivision 14.

Violation: The license holder did not establish a PAPP (Program Abuse Prevention Plan), as required.

The license holder did not establish a written PAPP, that included:

· an assessment of the population, including an evaluation of the following factors:

o age, gender, mental functioning, physical and emotional health or behavior of the client;

o the need for specialized programs of care for clients;

o the need for training of staff to meet identified individual needs; and

o the knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients;

· an assessment of the physical plant where the licensed services were provided, including an evaluation of the following factors:

o the condition and design of the building as it relates to the safety of the clients; and

o the existence of areas in the building which are difficult to supervise; and

· an assessment of the environment for the facility, including an evaluation of the following factors:

o the location of the program in a particular neighborhood or community;

o the type of grounds and terrain surrounding the building;

o the type of internal programming;

o the program's staffing patterns; and

· a statement of specific measures to be taken to minimize the risk of abuse.

Additionally, the license holder did not review the PAPP at least annually.

Corrective Action Ordered: Within 30 days of receiving this order, you must establish a PAPP that includes the information detailed above. A copy of the PAPP must be posted in a prominent location in the program. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions.

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

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