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March 10, 2026 Victor Makori, Authorized Agent Loving Caring Home Care LLC 17017 Georgetown Way Rosemount, MN 55068 License Number: 1095209 (245D - HCBS) NOTICE OF NONCOMPLIANCE WITH THE TERMS OF A CONDITIONAL LICENSE AND CORRECTION ORDER Dear Victor Makori: On August 29, 2025, the Department of Human Services (DHS) issued an Order of Conditional License to Loving Caring Home Care LLC, located at 17017 Georgetown Way, Rosemount, MN. On January 27, 2026, DHS licensors conducted a licensing review to determine whether compliance with the Terms of the Conditional License had been met. As a result of this review, DHS determined 16 home and community-based services licensing violations, and noncompliance with two terms in the Order of Conditional License. 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. NOTICE OF NONCOMPLIANCE WITH THE TERMS OF CONDITIONAL LICENSE On January 27, 2026, DHS determined that you did not follow 2 of 6 terms of the Order of Conditional License that is in place from August 29, 2025, to August 29, 2027. TERM #1 ON CONDITIONAL: You were ordered to notify current persons served receiving services, all parties who refer persons served to the program and all payer sources of the conditional statutes of your license within 15 days of receipt of your conditional order. You were required to submit a draft notice to DHS for approval within 10 days of receipt of the conditional order. The notice was not submitted to DHS until October 16, 2025. TERM #2 ON CONDITIONAL: You were ordered to Submit a designated coordinator and designated manager to DHS within 30 days of receipt the conditional order. You did not make a designated coordinator and designated manager submission to DHS until November 15, 2025. Legal Authority: Minnesota Statutes, sections 245A.06, subdivision 3; and 245A.07, subdivision 3(a). CORRECTION ORDER DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight 1. Violation: The license holder did not ensure program coordination, evaluation and oversight as required. a. The license holder did not ensure that the designated coordinator (SP3), provided coordination of service delivery and evaluation for each person served by the program. See citations 2 through 16 for the designation coordinators failure to provide supervision, support, and evaluation of activities including: · oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. b. The license holder did not ensure that the designated manager (SP4) provided program management and oversight of the services provided by the license holder. See citations 2 through 16 and the noncompliance with the terms of conditional license for the designated manager’s failure to: · maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Statutes Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: • ensure all staff persons identified as designated coordinators and designated managers for the program understand and have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and • maintain a signed document that the designated coordinators and designated managers have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records. On an ongoing basis, you must maintain compliance as required in this subdivision. Person Served Record Violations 2. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not provide orientation and review abuse prevention plans as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. b. The license holder did not provide P1 with orientation to the program abuse prevention plan within 24 hours of admission. The license holder initiated services with P1 on July 12, 2025 and provided this orientation on July 25, 2025. c. The license holder did not review P2’s individual abuse prevention plan (IAPP) with P2’s interdisciplinary team annually in 2025. Statutes Violated: Minnesota Statutes, section 245A.65, subdivision 2. Corrective Action Required: Within 30 days of receiving this order, you must review P2’s IAPP with P2’s interdisciplinary team and maintain documentation of this review. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide the service recipient rights. a. The license holder did not provide P1 with the service recipient rights within five working days of service initiation that included the following rights: · have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person; · have access to three nutritionally balanced meals and nutritious snacks between meals each day; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person's bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; · a setting that is free from hazards that threaten the person's health or safety; and · a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code. b. The license holder did not provide P2 with a written notice that identified the service rights annually in 2025. Statute Violated: Minnesota Statutes, section 245D.04. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Required: Within 30 days of receiving this order, you must provide P1 and P2 with all of the service recipient rights identified in Minnesota Statutes, section 245D.04. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Violation: For one person whose record was reviewed P1, the license holder did not document health needs as required. The license holder was assigned responsibility of meeting P1’s health needs. The license holder did not maintain documentation on how P1’s health needs would be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health service appointments. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1. Corrective Action Required: Within 30 days of receiving this order, you must document a description of how the above health needs would be met for P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Violation: For one person whose record was reviewed (P1), the license holder did not complete initial service planning as required. The license holder did not meet with P1, and P1’s case manager before providing 45 days of service to determine: · the scope of the services to be provided to support the person's daily needs and activities; · the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; · the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; · how technology might be used to meet P1’s desired outcomes. The license holder completed this on October 31, 2025. The license holder discussed how P1 could use technology; however, the license holder did not discuss how technology might be used to meet P1’s desired outcomes. Statute Violated: Minnesota Statutes, 245D.071, subdivision 3, paragraphs (a), (c), and (d). Corrective Action Required: Within 30 days of receiving this order, you must meet with P1 and P1’s case manager to discuss how technology might be used to meet the person's desired outcomes. The support plan or support plan addendum must include a summary of this discussion, including a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments as required. The license holder did not complete assessments for P1 in the following areas before providing 45 days of service: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. The license holder completed this on October 31, 2025. Statute Violated: Minnesota statutes, section 245D.071, subdivision 3, paragraph (b). Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Required: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete service outcomes and supports as required. a. The license holder did not develop a service plan that documented service outcomes and supports for P1 within 10 working days of the required timeline for the initial planning meeting. The license holder developed this on October 31, 2025; however, the license holder did not document the following supports and methods to be implemented to support and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental and emotional health and well-being, including: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o techniques that are consistent with the person's communication mode and learning style; and · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected. b. The license holder did not document the techniques that were consistent with P2’s communication mode used to support P2 and to accomplish the service outcomes. Statute Violated: Minnesota statutes, section 245D.071, subdivision 4. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Required: Within 30 days of receiving this order, you must review and revise P1’s and P2’s outcomes to document the all required supports and methods. On an ongoing basis, you must maintain compliance as required in this subdivision 8. Violation: For one person whose record was reviewed (P2), the license holder did not complete service plan review and evaluation as required. The license holder did not meet with P2, P2’s case manager, and other people as identified by P2 to participate in service plan review meetings at least once per year to: · determine whether changes are needed to the service plan based on the assessment information, the license holder’s evaluation of progress toward accomplishing outcomes, or other information provided by the support team or expanded support team; · discuss how technology might be used to meet P2’s desired outcomes and include a summary of this discussion that includes a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made in P2’s support plan addendum; · discuss options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider and include a summary of the discussion that includes a statement about any decision made regarding transitioning out of a provider-controlled setting and a description of any further research or education that must be completed before a decision can be made in P2’s support plan addendum; and · summarize P2’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P2, P2’s case manager, and other people identified by P2 for a service plan review meeting to determine, discuss and summarize the requirement identified above. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. 9. Violation: For one person whose record was reviewed (P1), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder did not inform P1 and P1’s case manager of the policies and procedures effective a person’s right, and provide a copy of those policies and procedures within 5 days of service initiation: · service suspension policy; · termination policy, · emergency use of manual restraints policy; and · data privacy policy. Additionally, the license holder did not provide P1’s case manager with a copy of the grievance policy. Statute Violated: Minnesota Statues, section 245D.10, subdivision 4. Corrective Action Required: Within 30 days of receiving this order, you must provide P1 and P1’s case manager with the above mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Violation: For one person whose record was reviewed (P1), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required. At the time of service initiation, the license holder did not obtain a written acknowledgement from P1’s legal representative indicating that P1 had been notified of the license holder’s emergency use of manual restraint policy and their rights under this chapter and Minnesota Statutes, section 245D.04. Statute Violated: Minnesota Rules, part 9544.0080, subpart 1. Corrective Action Required: Within 30 days of receiving this order, you must obtain the above-mentioned written acknowledgement from P1’s legal representative. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Violation: For one person whose record was reviewed (P1), the license holder did not ensure the protection and exercise of the service recipient rights as required. The license holder did not ensure the protection and exercise of P1’s right to engage in chosen activities. The license holder maintained documentation in P1’s prohibiting P1 from eating in their own room and prohibiting the presence of alcohol in the residence. Statute Violated: Minnesota statutes, section 245D.04. Corrective Action Required: Within 30 days of receiving this order, you must restore all of P1’s service recipient rights. On an ongoing basis, you must maintain compliance as required in this subdivision. Staff Person Record Violations 12. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did provide orientation to the program abuse prevention plan (PAPP) as required. The license holder did not provide SP2 with orientation to the PAPP within 72 hours of first providing direct contact with person served by the program. SP2’s date of first contact with persons served by the program was August 18, 2025. The license holder did not provide orientation to the PAPP until November 14, 2025. Statute Violated: Minnesota statutes, section 245A.065, subdivision 3. Corrective Action Required: On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide and ensure completion of orientation training as required. SP2 was hired on August 18, 2025. The license holder did not provide and ensure completion of the following orientation training within 60 days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures. These were provide on November 14, 2025; · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · sections 245A.65, and 626.557 and chapter 260E governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Statute Violated: Minnesota Statues, section 245D.09, subdivision 4. Corrective Action Required: Withing 30 days of receiving this order, you must provide SP2 with the above-mentioned orientation training. 14. Violation: For one person whose record was reviewed (SP2), the license holder did provide orientation to the individual service recipient needs as required. The license holder did not provide SP2 with orientation to the individuals service recipient needs before having unsupervised direct contact with persons served by the program. This was provided on November 14, 2025. Statute Violated: Minnesota statutes, section 245D.09, subdivision 4a. Corrective Action Required: On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training as required. The license holder did not provide SP1 with the following required annual training: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with the above required annual training. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota statutes, section 245D.09. subdivision 5. 16. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain staff personnel records as required. a. The license holder did not maintain a personnel record for SP1 that included: · SP1’s date of hire; · a completed application; · an acknowledgement signed by the employee that job duties were reviewed with the employee and the employee understood those duties; · documentation that the employee met the position requirements as determined by the license holder; · documentation of SP1’s qualifications; · performance evaluations as required under section 245D.09, subdivisions 3 to 5; and · orientation and training that included; o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. b. The license holder did not maintain a staff personnel record for SP2 that included an acknowledgement signed by SP2 that the job duties were reviewed and documentation of staff qualifications. Statute Violated: Minnesota statutes, section 245D.095, subdivision 5. Repeat Violation: In an Order of Conditional License DHS issued August 29, 2025, you were previously found in violation of this same Statute. Corrective Action Required: Within 30 days of receiving this order, you must maintain staff personnel records for SP1 and SP2 that include the above. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 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 Licensing Division Attention: 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. · Home and community based services are required to follow Minnesota Statutes, chapter 245D. · 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 Troy Goudy, Supervisor, at 651-431-3658. Sincerely, Robert Romani, HCBS Licensor Licensing Division Office of Inspector General
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