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June 26, 2026 CERTIFIED MAIL J Vang, Authorized Agent Care Plus PCA Inc 1299 Arcade Street Suite 100 Saint Paul, Minnesota 55106 License Number: 1107814 (Home and Community Based Services) ORDER OF CONDITIONAL LICENSE Dear J Vang: The Department of Human Services (DHS) is placing your license to provide at Care Plus PCA Inc, 1299 Arcade Street, Saint Paul, Minnesota, on conditional status for two years, beginning June 26, 2026. This means you must meet certain conditions to maintain your license, detailed below. This order applies to all services licensed under Chapter 245D and the service sites detailed in the “Applicability of Conditional License” section below. This order is based on your noncompliance with Home and Community Based licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On February 26, 2026, DHS licensors conducted a licensing review at your facility located at 1299 Arcade Street, Saint Paul, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program did not comply with the laws and rules that apply to licensed Home and Community Based Services, citing 12 violations. Licensing Violations Determined on February 26, 2026 DHS determined that your program did not follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight 1. Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight. a. The license holder did not ensure that the designated coordinator (SP5), provided supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s support plan 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 support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. 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 that include: · maintaining 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 (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of the satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person’s rights as identified in section 245D.04; · 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, subdivision 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. See citations two through twelve for the designated coordinator and designated manager’s inability to fulfill the above stated requirements. Statute Violated: Minnesota Statutes, section 245D.081. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, you were previously found in violation of this same statute. Corrective Action Required: Within 30 days of receiving this order you must: · designate a staff person other than SP4 or SP5 to be responsible for the coordination and evaluation of individual service delivery and ensure that the individual meets the education, training and work experience requirements outlined in 245D.081, subdivision 2); · designate a managerial staff person or persons other than SP4 or SP5 to be responsible for the program coordination, evaluation, and oversight of services provided and ensure that individual meets the education, training, and work experience requirements outlined in 245D.081, subdivision 3; and · provide your licensor with the names and qualifications of the individuals that will be responsible for the job duties of the designated coordinator and designated manager. On an ongoing basis, you must maintain compliance as required in this subdivision. Service Recipient Violations 2. Violation: For four of four persons whose records were reviewed (P1-P4), the license holder did not establish and enforce individual abuse prevention plans (IAPP) as required. a. The license holder did not establish an IAPP for P1 that included an individualized assessment of P1’s susceptibility to abuse. P1’s IAPP indicated that P1 was not susceptible to abuse. This assessment was not consistent with information maintained in P1’s record that documented P1’s susceptibility to physical abuse and self-abuse. b. The license holder did not develop an IAPP for P2 that included a statement of measures that would be taken to minimize the risk of abuse to P2 within the scope of licensed services. Additionally, the license holder did not review P2’s IAPP at least annually in 2025. P2’s IAPP was last reviewed on December 20, 2024. c. The license holder did not establish an IAPP for P3 that included an individualized assessment of P3’s susceptibility to abuse and statements of the specific measures to be taken to minimize the risk of abuse. P3’s IAPP indicated that P3 was not susceptible to abuse. This assessment was not consistent with information maintained in P3’s record that documented P3’s susceptibility to physical abuse and self-abuse. d. The license holder did not develop an IAPP for P4 that included a statement of measures that would be taken to minimize the risk of abuse to P4 within the scope of licensed services. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was ordered to complete an IAPP for P2 and P4 that included an assessment of P2’s and P4’s susceptibility to abuse and statements of the specific actions that would be taken to minimize the risk of abuse to P2 and P4 within 60 days of receiving the correction order. The license holder did not comply with the corrective action ordered by DHS. Corrective Action Required: Within 60 days of receiving this order, you must: · revise the IAPP’s for P1-P4 to include the information that meets the requirements of this section; · review the revised IAPP’s for P1-P4 with the person, their case manager, and their legal representatives as applicable; · provide orientation to the revised IAPP’s for P1-P4 to staff and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; and · submit a copy of the IAPP’s for P1-P4 to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Violation: For one person whose record was reviewed (P2), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder did not provide P2 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was found to be in violation of this same statute. Corrective Action Required: Within 60 days of receiving this order, you must provide P2 with the service recipient rights and maintain a copy of the receipt of service recipient rights in P2’s service plan. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Violation: For two persons whose record were reviewed (P3 and P4), the license holder did not provide services in response to the person’s identified needs, interests, and preferences as required. The license holder did not ensure that P3’s and P4’s support plan addendums identified what is important to P3 and P4 as well as what is important for P3 and P4, including preferences for when, how, and by whom direct support service is provided. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was found in violation of this same statute. Corrective Action Required: Within 60 days of receiving this order, you must update the service plans for P3 and P4 to include the information required by this statute. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Violation: For one person whose record was reviewed (P3), the license holder did not complete initial service planning for basic services as required. The license holder initiated basic services for P3 on June 1, 2025. The license holder did not, within 60 calendar days of service initiation, review and revise as needed, the preliminary support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2. Corrective Action Required: Within 60 days of receiving this order, you must update the support plan addendum for P3 to include the information required by this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes that are recorded by the program in the service recipient records for P1-P4. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was ordered to maintain progress or daily log notes for P2 and P4 on an ongoing basis. The license holder did not comply with the corrective action ordered by DHS. Corrective Action Required: Concerns regarding the provider’s daily log notes and billing for home and community-based services were referred to the Department of Human Services, Office of Inspector General, Program Integrity and Oversight Division. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Violation: For three persons whose records were reviewed (P1, P3, and P4), the license holder did not ensure access to the service recipient record as required. The license holder did not ensure that staff working with P1, P3, and P4 had access to the service recipient records including information relevant to carrying out the support plan or support plan addendum. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 4. Corrective Action Required: Within 60 days of receiving this order, you must ensure that staff have access to service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Violation: For one person whose record was reviewed (P5), the license holder did not provide notice of service termination as required. The license holder provided a basic service to P5. The license holder did not provide the service termination for P5 at least 30 days prior to termination. The service termination notice was dated January 29, 2026, with an effective date of January 28, 2026. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 3a, paragraph (a). Corrective Action Required: Within 60 days of receiving this order, you must provide training to all staff on your service termination policy and maintain documentation of this training according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide written or electronic copes of policies and procedures as required. The license holder did not inform P1’s-P4’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation: · grievance policy; · service suspension and termination policy; and · emergency use of manual restraints policy. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was ordered to provide the policies listed above to P4’s case manager within 60 days of receiving the order. The license holder did not comply with the corrective action ordered by DHS. Corrective Action Required: Within 60 days of receiving this order, you must provide the policies listed above to P1’s-P4’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not implement or evaluate positive support strategies as required. a. The license holder did not incorporate positive support strategies for P1 in writing to an existing treatment, service, or other individual plan required of the license holder. b. The license holder did not evaluate identified positive support strategies with P2 at least every six months. Rule Violated: Minnesota Rules, part 9544.0030, subpart 1. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was ordered to evaluate P2’s identified positive support strategies at least every six months. The license holder did not comply with the corrective action ordered by DHS. Corrective Action Required: Within 60 days of receiving this order, you must: · incorporate positive support strategies for P1 in writing to their individual plans; · evaluate identified positive support strategies with P1 and P2 at least every six months; and · based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subdivision. Staffing Standards Violations 11. Violation: For one of five staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. The license holder did not provide SP2 with an orientation to the following topics: · data privacy requirements and staff responsibilities related to complying with data privacy practices; · 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; and · basic first aid. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, you were previously found in violation of this same statute. Corrective Action Required: Within 60 days of receiving this order, you must provide and ensure completion of the trainings listed above for SP2 and maintain documentation of this training according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide annual training as required. The license holder did not provide SP1 and SP3 with annual training on 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. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on August 14, 2025, the license holder was ordered to provide training on prohibited procedures to SP1 and SP3 within 30 days of receiving the order. The license holder did not comply with the corrective action ordered by DHS. Corrective Action Required: Within 60 days of receiving this order, you must provide and ensure completion of the trainings listed above for SP1 and SP3. On an ongoing basis, you must maintain compliance as required in this subdivision. Nature, chronicity, or severity of violations and effect of violation(s) on health, safety, or rights of persons served by the program The Commissioner has considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a conditional license is appropriate. · Nature: The license holder was issued a correction order on August 14, 2025. The correction order contained 18 citations with corrective action ordered to be completed for each violation. Despite the corrective action that was ordered in that correction order, the license holder continued to demonstrate noncompliance and did not provide program coordination, evaluation, and oversight of services at the time of the licensing review on February 25, 2026. · Chronicity: Your program received its license on February 16, 2021. Since that time, your program has demonstrated noncompliance with licensing rules and statutes. The information below summarizes this history: o June 26, 2026 Conditional License (this order): 12 violations (9 repeat) o August 14, 2025 Correction Order: 18 violations o August 29, 2022 Correction Order: 1 violation · Severity: Many of the violations involve your inability to complete service planning requirements, conduct ongoing evaluation of the services provided, and develop abuse prevention plans. Insufficient completion of service planning requirements and ongoing evaluation of services provided to persons served could result in service recipients not receiving accurate, safe, adequate, and compliant services from appropriately trained staff. Assessing abuse risks and creating a plan to minimize such risk is not a mere technical exercise in regulatory documentation. The IAPP is a critical document that informs the safe provision of services to vulnerable adults. The IAPP also informs your staff how to prevent the risk of abuse and identifies positive support strategies staff can use in service delivery. These violations relate to the health, safety, and well-being of persons served and put their health and safety at risk. You did not complete many of the corrective actions ordered in the August 14, 2025, correction order. Corrective actions are ordered to ensure that the identified violations are resolved that are related to health, safety, or rights. Because you didn’t address those corrective actions, the noncompliance remains in place, meaning individuals may continue to be exposed to substandard care. Your inability to follow through on clearly defined corrective steps calls into question whether you have the competency in management and coordination positions, trained direct care staff, or processes in place to maintain compliance on an ongoing basis. As an example, you were ordered to maintain progress or daily log notes documented by the program in the service recipient records. You did not implement this action as ordered. Log notes serve as essential documentation that required services are being delivered as intended. When these records are absent, it raises legitimate concerns about whether services are being consistently provided in accordance with established requirements. The designated coordinator and designated manager did not provide the program management and oversight required to ensure your program remains in compliance with licensing requirements. License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of your inability to hire a qualified designated coordinator and designated manager, you were found in violation of the 12 citations described in this order. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the program’s operation, well-being of persons served by your program, available evaluations of the program by persons receiving services, the qualifications of staff persons, the ability to demonstrate competent knowledge of applicable laws and rules, and the results of background studies. Based on the Commissioner’s evaluation of the program, DHS is concerned about the program’s operation, the well-being of persons served by your program, the qualifications of staff persons, and the ability to demonstrate competent knowledge of applicable laws and rules. DHS is concerned about the program's operation because the needs of persons served were not adequately documented in records and staff were not properly trained. Without daily log notes it is not possible for the Commissioner to ensure that services occurred, or that services were provided according to statute requirements. Additionally, little distinction was made between 245D services and the home care services that are also provided by your agency. The number of violations and the fact that many of them were repeat violations demonstrates that you did not adequately oversee your responsibilities as a license Holder, to ensure compliance, and take corrective action when ordered by the Commissioner. Based on the Commissioner’s evaluation of the program, a conditional license is warranted. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services is placed on a conditional license. Corrective action required You must correct the violations as described above. Compliance with this order will be reviewed on-going. If you do not demonstrate substantial compliance with home and community-based service requirements and with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the twelve violations (nine repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. Since the violations involved your lack of competence to hire and train competent designated coordinators and designated managers; they involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). CONDITIONAL LICENSE TERMS 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, other than SP4 or SP5, to provide coordination and evaluation of individual service delivery; · designate a managerial staff person, other than SP4 or SP5, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the person(s) who will fulfill the duties and responsibilities of the designated coordinator and designated manager for DHS review and approval. The same person may work in both roles if they meet the necessary qualifications. You are responsible for ensuring the person(s) meet the necessary qualifications. You must maintain documentation of your designated coordinators and designated manager’s qualifications in their personnel record and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS for the duration of the conditional order. 3. Within 60 days of receiving this order, you must: · complete an audit of all person served and personnel records. The audit must be completed by your designated coordinator and/or designated manager; 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. 4. You may not add additional services to your current license for the duration of the conditional license. 5. You will not be granted any variances for the duration of the conditional license. 6. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 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 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for three years from that date. You continue to be required to comply with all 245D laws and rules. 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 245A, 245C and 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Leota Bemis, Supervisor, at 651-431-5637. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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