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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1108472-CRF (Children’s Residential Facility) Investigator(s): Samantha Wueste Samantha.wueste@state.mn.us Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) each had inappropriate interactions and sexual contact with an alleged victim (AV) on multiple occasions. During the course of the investigation, it was reported that another staff person (SP3) made inappropriate comments when interacting with the AV and another youth (Y2). Date of Incident(s): Ongoing between November 1 and December 15, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 20; and subdivision 15, paragraph (a), clauses (1) and (2): "Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse. Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a visit conducted on January 8, 2026; from documentation at the facility, law enforcement (LE) records, and medical records; and through 23 interviews conducted with the AV’s family members (FM1 and FM2), four youth (Y1, Y2, Y4, and Y6) who resided at the facility, Y2’s family member (FM4), Y4’s family member (FM6), Y6’s family member (FM8), Y8’s family member (FM9), Y9’s family member (FM10), Y11’s family member (FM12), five facility staff persons (SP1-SP3, P1, and P2), a facility staff person (P3) who was a therapist, a facility staff person (P11) who was a counselor, a supervisory staff person (P4), two administrative staff persons (P5 and P6), and a medical healthcare professional (MHP) who specialized in the forensic interviewing of children of possible sexual abuse. The AV was interviewed by the MHP, which was included below. Additionally, subsequent phone calls were made to FM1 to obtain additional information and documentation that s/he had regarding these allegations. However, the documentation was not provided by the completion of this investigation. Multiple attempts were made via phone to contact and interview five additional facility staff persons (P7, P8, and P16-P18), two additional supervisory staff persons (P9 and P10), two staff person (P12 and P13) who were facility counselors, a facility staff person (P14) who was a nurse, and another administrative staff person (P15), but the attempts were not successful. However, P7, P8, P10, and P14-P17 provided information in the AV’s Shift Notes and for the facility’s Internal Review which was included below. Multiple attempts were also made via phone to contact seven additional youth (Y3, Y5, and Y7-Y10) and their respective family members, but the attempts were not successful. However, Y3 and Y5 provided information to facility administrative persons and Y5 also provided information to a law enforcement officer (LEO2) which were included below. The AV enjoyed being outdoors, exercising, going shopping, listening to music, playing volleyball, and spending time with his/her family members and friends. The AV resided at the facility between October 30 and December 16, 2025, and was 15 years old. Prior to and after the AV’s placement at the facility, the AV lived with FM1, FM2, and an additional family member (FM3). The facility was a residential treatment center for youth ages 13 to 18 years who had a history of substance abuse and/or mental health concerns. Youth who lived at the facility were provided with supports and services that included individualized case management, supervision, health and behavior management, gaining/continuing education, individual/group/family therapy, building social support and independent life skills, recreational activities, and accessing mental health services and community resources. The facility operated/staffed three shifts: 7:30 a.m. to 3:30 p.m. (day, “AM shift”), 2:30 to 10:30 p.m. (evening, “PM shift”), and 10 p.m. to 8 a.m. (overnight/nocturnal, “NOC shift”). During and between shifts, staff persons communicated with one another using Teams (a messaging application) that was synced on all facility-owned devices including laptops/phones used by supervisory/administrative staff persons and mobile phones that direct care staff shared and acquired before working a shift. The facility was a campus style setting with multiple buildings, parking lots, and grassy/wooded areas. Within the campus, each building contained shared common areas and rooms that were used for various programming needs including multiple classrooms, therapy rooms, lounge/recreational rooms, nursing spaces, and gyms that connected to exercise rooms. The facility also had six separate “cottages” where youth lived which were able to actively house/support up to ten youth per cottage and were assigned based on a youth’s gender and the area of care/treatment required. During the AV’s placement at the facility, s/he lived in cottage 3 with 11 other youth (Y1-Y11). Additionally, each cottage and building within the campus (except the “Busch Building”) was connected to other parts of the facility through secured hallways and corridors. The main level of cottage 3 had an open and accessible floor plan with a secured front entry way that led directly into a large centralized common area/hallway (the “main hall”). The main hall contained a shared bathroom, a supervisory staff office, a counselor’s office, and a staircase to the basement. To the left of the main hall was a living room that connected to a laundry room and an accessible youth bedroom which included a private bathroom. To the right of the main hall was a study/dining area with an attached kitchenette that connected to a medication room and a staircase leading to the upper level of the cottage. The upper level consisted of five shared youth bedrooms with two youth assigned to each bedroom, a shared multi-person bathroom that connected to a small sitting room (the “day room”), a staff area, and a staircase to the attic. Youth personal care items were kept in a closet across from the upper-level bathroom that was to be locked when not in use and only accessed by staff persons. At the time of the incidents, the basement and attic of the cottage were not spaces that were used by the program. While living at the facility, the AV occupied two different bedrooms within the upper level of the cottage, first sharing a bedroom with Y10. However, there were multiple ongoing interpersonal conflicts between the AV and Y10 and so at some point during late November 2025, the AV was reassigned to share a bedroom with Y1 for the remainder of his/her placement at the facility. At the time of this investigation, the AV, Y1-Y3, Y5, Y6, and Y8-Y11 no longer resided at the facility. The facility had cameras mounted at all exterior entrances/exits throughout the campus, in hallways/corridors, and within some of the common areas, which recorded video but not audio. There were also multiple areas within the facility that did not have cameras which included some of the gyms, the exercise/weight rooms, and rooms used for youth programming. In cottage 3, there were two cameras on the cottage’s main level that overlooked the kitchenette and the medication room, and a third camera mounted above the staircase leading to the upper level. According to the facility’s Program Abuse Prevention Plan, cottage 3 maintained a minimum of 1:6 staffing during each shift with at least one staff person located on each level of the cottage where youth were present. During the entirety of the AV’s placement at the facility, there was another youth (Y5) who used a wheelchair and was assigned the accessible bedroom located on the main level. Therefore, during the overnight shift, one staff person worked on the main level of the cottage and a second staff person worked on the upper level. Staff persons working on the main level in the living room, laundry room, and/or one of the staff offices near Y5’s bedroom would not be able to see or hear interactions on the upper level. The AV’s file provided the following information: · On October 30, 2025, the AV was admitted to the facility to help manage his/her mental health and behaviors. The AV was discharged on December 16, 2025. · The AV’s Vulnerability Assessment and Sexual Abusive Behavior Screen and Cultural Screening dated October 30, 2025, showed that the AV had a history of being emotionally, physically, and sexually abused by others. The AV did not have a history of sexually abusive behaviors towards others or having inappropriate interactions. The facility’s Code of Conduct stated that “all” staff persons “must” maintain a professional relationship with youth and were not permitted to become “romantically or sexually involved” with youth or to engage in “any type of relationship” with youth that included electronic communication via email or social media. Additionally, the facility had “zero tolerance” for incidents involving staff persons having sexual contact with youth and/or engaging in “conversations of flirtatious nature or sexual innuendo” when interacting with youth. Facility documentation showed that all facility staff persons who provided information for this investigation (including SP1, SP2, and SP3) were trained on the Reporting of Maltreatment on Minors and the facility’s Code of Conduct prior to the incident. Regarding SP1’s and SP2’s inappropriate interactions and sexual contact with the AV: Facility documentation related to recording and reporting incidents provided the following information: · On December 11, 2025, Y1 had an individual therapy session with P3. During the session, Y1 told P3 that there were multiple incidents where unidentified staff persons (later determined to be SP1 and SP2) engaged in “sexual activities” with an unidentified youth (later determined to be the AV). However, Y1 was not “comfortable” “sharing” any identifying information about the staff and/or youth involved in the incidents with P3 at that time because Y1 “believed” it was “not [his/her] place to say anything.” P3 then asked Y1 if the incidents involved “sex” and Y1 responded, “No, one step down from that,” with the most recent incident occurring about seven days prior. · After talking with Y1, P3 contacted and notified the facility’s administrative team about the incidents that Y1 reported to him/her. Later that day, P6 attempted to talk to Y1 about what s/he told P3 but Y1 refused to talk with P6 at that time. P5 and P6 talked with the AV, Y2, Y3, and Y4 about the allegations and each youth denied that there were any incidents of a staff person having sexual contact with each. P5/P6 also attempted to talk with Y1 about the concerns s/he reported to P3 but Y1 declined to provide any additional information at that time. The AV’s medical records, the MHP, and the information the AV provided to the MHP during the forensic interview included the following: · On February 3, 2026, FM1 contacted law enforcement (LE) and spoke to a law enforcement officer (LEO2) regarding concerns of possible sexual assault of the AV that occurred while the AV was living at the facility. · On February 6, 2026, prior to the AV’s forensic interview, FM1 and FM2 spoke to the MHP. FM1 and FM2 told the MHP that after the AV was discharged from the facility, the AV began to have frequent “outbursts” and “arguments” with his/her family members that led to the AV telling FM1 about being “touched” and “kissed” by two staff persons while at the facility. · During the AV’s forensic interview, the AV stated that there were multiple incidents when two facility staff persons “molested” the AV. The AV identified each staff person (later determined to be SP1 and SP2) by their first names, gender, and estimated age. The AV further described “molested” as times “when [SP1 and SP2] would just kiss and touch me and made me touch them and stuff.” The “touches and kisses” occurred six to seven times on unknown dates/times. The incidents started occurring shortly after the AV arrived at the facility and occurred on a weekly basis during times when SP1 or SP2 were able to “get [the AV] somewhere private and alone.” The AV said that the incidents occurred in areas of the facility that were not monitored by surveillance cameras which included the upper level of cottage 3 (the bathroom and the day room) and shared common areas/rooms within the campus (the workout room connected to the north gym and the meditation/yoga room). · The AV thought the first incident occurred in “early” November 2025, around the first week of his/her placement at the facility during an overnight shift when SP1 worked in cottage 3 and the AV had difficulty sleeping. At some point during that night ,while the other youth (later determined to be Y2, Y5, Y6, Y8, Y9, and Y10) in the cottage slept, the AV approached SP1 who was the only staff person working on the cottage’s upper level and asked for his/her personal care items that were stored in a secured closet near the bathroom. SP1 unlocked the closet and while the AV was getting his/her items, the AV “noticed” that SP1 was “looking at [him/her] in a certain way.” SP1 then began talking with and complimenting the AV. After the AV got his/her items from the closet, SP1 and the AV went to the day room, sat on the couches, and SP1 “let [the AV] look” at SP1’s phone which “surprised” the AV because youth were “not allowed” to access or have phones at the facility. SP1 then showed the AV photos on his/her phone of “all [SP1’s] money, guns, and cars and stuff” and told the AV that s/he “could get [the AV] money and a car and probably drugs too.” The AV then told the MHP, “Which was one of the reasons I was in there (at the facility), for substance abuse.” · At some point, SP1 stood up and left the day room to do the health/safety checks of the youth. The AV then also left the day room and went into the bathroom to complete his/her personal cares. After completing checks, SP1 came into the bathroom and approached the AV. SP1 “turned [the AV] to face the bathroom mirror, hugged [the AV], and told [the AV] how [beautiful/handsome] [s/he] was. Then [SP1] started kissing [the AV] on [his/her] neck and mouth” and “grabbing [the AV] in places like [the AV’s] butt and stuff” over AV1’s clothing. After an unknown amount of time later, SP1 exposed his/her genitalia to the AV and asked for oral sex from the AV but the AV told SP1 that s/he did not want to do this. SP1 then “kept asking” for oral sex from the AV and told the AV to “spit” on the SP’s genitalia, so the AV spit on SP1’s genitalia but did not perform oral sex as requested by SP1. “Soon” after this, SP1 left the bathroom to complete the healthy/safety checks again and the AV returned to his/her bedroom and went to sleep. The AV told the MHP, “But then it happened again another time.” · The second incident occurred about one week after the first incident and was “pretty much the same thing” as the first time. During an overnight shift, while SP1 worked and the other youth slept, SP1 and the AV went into the upper-level bathroom and “kissed and stuff.” SP1 then exposed his/her genitalia to the AV and asked the AV to perform oral sex on SP1 but the AV said, “No.” SP1 then put the AV’s hand on SP1’s genitalia. SP1 also kissed the AV on his/her neck and lips, kissed “the outside and inside” of the AV’s lips/mouth, and “grabbed” and placed the AV’s hand on SP1’s genitalia. SP1 then placed his/her own hand on top of the AV’s hand and moved the AV’s hand on SP1’s genitals. SP1 eventually stopped and the AV returned to his/her bedroom and went to sleep. · The AV said there was also an incident when SP1 pulled off the AV’s pants but the AV still wore his/her underwear. SP1 touched his/her genitals on the AV’s buttocks and the AV told SP1 that s/he did not like that. · The AV told the MHP that SP2 also engaged in the same interactions with the AV. The AV told the MHP that “the very first time with [SP2]” was similar to the incidents involving SP1. The AV could not sleep and was awake during over the night shift when SP2 was working. At an unknown time, while the other youth slept, the AV left his/her bedroom and was sitting alone in the day room, which had no cameras. SP2 came into the room and sat with the AV and asked the AV if s/he “wanted to play a game” where the AV had to try and “get something” from SP2. The AV agreed and SP2 held up his/her Chapstick. The AV walked to SP2 and tried to get the Chapstick from SP2, but then SP2 put the item in his/her front pant pocket. The AV reached into SP2’s pocket and felt SP2’s genitalia through SP2’s clothing. When the AV tried to take his/her hand out, SP2 “held” the AV’s hand inside SP2’s pocket and against SP2’s genitalia while looking at the AV. Shortly thereafter, SP2 began “kissing” the AV “a lot” on “the outside and inside” of the AV’s lips/mouth and “grinded against” the AV over the AV’s and SP2’s clothing for an unknown amount of time before stopping. SP2 then left the day room to do health/safety checks and the AV returned to his/her bedroom and went to sleep. · On another occasion, SP2 took the AV’s shirt off and “played with [the AV’s] breasts and stuff.” [Note: The use of the word breast/boob should not be used as an indicator of the gender and/or genitalia of the persons involved in this investigation.] SP2 touched the AV’s breasts with his/her hands and mouth underneath the AV’s clothing. · The AV said that on one occasion while in the gym, SP2 again played the game where the AV had to get something from SP2, but with a ball. The AV “already knew what was about to happen but this time was more different than any of the other times.” As the AV tried to get the ball from SP2, SP2 “eventually” told the AV to “get on the ground.” The AV asked, “Why?” and SP2 said, “Just do it,” so the AV sat down on the gym floor. SP2 then “grabbed” the back of the AV’s neck/head, “pushed” the AV’s body and head to the floor, and “got on top of [the AV] from behind.” SP2 then “rubbed” his/her clothed genitalia area against the AV’s clothed buttocks. “Eventually,” SP2 stood and walked towards the door telling the AV to “get up” and the AV did so. SP2 walked the AV back to cottage 3 and then left the area. · On another occasion when the AV was in the meditation/yoga room, SP2 entered and told the AV to “come here” while using a hand gesture indicating for the AV to “sit on [SP2’s] lap.” The AV did as SP2 told him/her. SP2 then began kissing the AV’s mouth/lips but stopped and told the AV to “get on the ground” and the AV did. SP2 then took off his/her pants and the AV’s pants so each were in their underwear. SP2 then rubbed his/her genitals on the AV’s buttocks while “grabbing” at the AV’s “back, shoulders, boobs, and anything [SP2] could reach.” The MHP documented that as the AV talked about the incidents, the AV’s body language and non-verbal cues indicated that the AV had difficulty talking about what happened during each of these incidents including the AV not making eye contact and wiping away tears. · SP1 and SP2 each “made a lot of false promises” to the AV that made the AV think that if s/he “went along” with these incidents, SP1 and/or SP2 would provide the AV with “cartilages and vapes” of products containing marijuana. SP1/SP2 “never” provided any illegal drugs or substances to the AV while s/he was living at the facility but SP1 asked the AV for his/her social media information so that SP1 could contact the AV after s/he was discharged from the facility and “promised” to “get [the AV] all the drugs [s/he] wanted.” On multiple unspecified dates after the AV was discharged from the facility on December 16, 2025, SP1 and SP2 each made multiple attempts to contact the AV via social media but the AV did not respond and “blocked” them. · The MHP stated that based on his/her evaluation and interview with the AV, it was determined that the AV was sexually assaulted. Y1 provided consistent information to LEO2 and this investigator on separate dates that included the following information: · Y1 lived in cottage 3 and was the AV’s roommate for a period of time. After Y1 and the AV became “roommates,” they began to talk and became “close” friends. On an unknown date/time during “early” December 2025, Y1 and the AV were talking in their bedroom about different life experiences they each had outside of the facility and started “sharing secrets” about themselves. During their conversation, the AV said that s/he was going to tell Y1 “something” but did not want anyone else to know and asked Y1 to “promise” “not to tell anybody,” which Y1 agreed to. The AV then started to tell Y1 about multiple incidents involving “intimate things” and sexual contact SP1 and SP2 each had with the AV at the facility on multiple occasions. The AV provided detailed information to Y1 about these incidents that was consistent with the information the AV provided in his/her interview with the MHP. · Two or three days later, Y1 told P3 what the AV said about SP1 and SP2. Then a day or two later, the AV also told Y5, Y6, and P15 about the incidents. · About “a week-and-a-half before Christmas,” Y1 and the AV were each discharged from the facility. Law enforcement (LE) records provided information that was consistent with the information provided by the MHP, the AV, and the AV’s medical records. The LE records also provided the following additional information: · On December 15, 2025, at 9:30 p.m., a law enforcement officer (LEO1) was dispatched to a residence located in a neighborhood near the facility for concerns regarding a youth (later determined to be Y1) who had asked a community person (C) for help. When LEO1 responded, Y1 told LEO1 that the AV was sexually assaulted by staff persons. LEO1 then drove to the facility and spoke with a different staff person who was working at that time (later determined to be P10) and who provided LEO1 with the AV’s full name. P10 told LEO1 that administrative staff persons were already aware of the allegations but “every time they questioned” the AV about the situation/concerns, the AV “refused” to provide “any information whatsoever.” Additionally, it was “believed” that these allegations were “unfounded.” P10 and LEO1 exchanged contact information and LEO1 left the facility. · On December 16, 2025, P5 called LEO1 and said that the facility received multiple “complaints” from multiple facility youth about multiple staff members which was a “situation [that] was beginning to snowball.” Administrative staff persons interviewed facility youth and staff persons who were potentially involved in this situation and removed any staff persons from the schedule while the facility looked into concerns. The case was then transferred to LEO2. · At the completion of this report, law enforcements investigation was ongoing. The AV’s Shift Notes (SN) and the facility’s Employee Timesheets and 15-Minitue Health and Safety Checks provided information that SP1 and SP2 worked evening and overnight shifts in cottage 3 with other staff persons. There were multiple dates when SP1 and SP2 completed checks and noted the AV was awake. At times when the AV was awake, staff persons interacted with the AV including once when SP1 took the AV outside “to walk around” the campus for approximately one hour before returning to the cottage and once when an unspecified staff person played music for the AV. The SN also documented that throughout the AV’s placement at the facility, the AV had ongoing maladaptive behaviors that involved behaviors the AV had a known history of engaging in but also included multiple incidents of behaviors that the AV did not have a history of engaging in including making inappropriate/sexual comments to other youth and engaging in inappropriate interactions with other youth of the opposite gender. P1-P6 and P11; the AV’s and Y1’s Treatment Notes (TN); and facility documentation provided the following information: · On December 11, 2025, at approximately 9:45 p.m., P2 and P7 were working in cottage 3. At that time, Y1 and Y5 were outside in a common area of campus near cottage 5 and “refused” to go inside. P7 remained outside with Y1 and Y5 while P2 went into cottage 3 with the other youth to get ready for bed. P7 attempted to redirect the youth to return to the cottage but Y1/Y5 each “ignored” P7 and remained outside. At some point during that time, P10 arrived on campus to work the overnight shift and was made aware of the situation. Shortly thereafter, P10 went to help P7 and approached the area where Y1 and Y5 were each sitting. P10 then sat beside Y1/Y5 and began talking to them while P7 remained nearby. At approximately 10:45 p.m., Y1 told P10 that the AV told him/her that the AV and SP2 were involved in a “sexual relationship.” Y1 further described “sexual activity” to include times where SP2 was “humping and making out” with the AV. However, Y1 “worried” that the AV “might get mad” at him/her for talking to P10 about the incidents and asked P10 “not to report” the information. Additionally, Y5 told P10 that on multiple occasions SP2 told Y5 that s/he was SP2’s “favorite” and asked Y5 if s/he was Y5’s “favorite staff” which Y5 “now found concerning.” · At 11:08 p.m., P7 text SP2 about what Y1 and Y5 told P10. SP2 then “immediately” text P5 about the situation and said the allegations were “not true” and requested to not work in cottage 3 until the situation was responded to by administrative staff persons. · At approximately 11:45 p.m., Y1 and Y5 each returned to cottage 3 and went to sleep. At that time, P10 completed an incident report about what Y1 and Y5 each said, removed SP2 from working in cottage 3, and submitted the report to the facility’s administrative team for further review/response. · From December 12 to 19, 2025, administrative staff persons conducted an internal review into the allegations and interviewed facility staff and youth who SP2 and/or the AV “regularly” worked/interacted with which included the following information: o On December 12, 2025, P3 and P5 attempted to talk to the AV about the reported concerns involving SP2 but the AV “initially refused” to provide any information at that time. Between December 13 and 15, 2025, P3, P4, and P5 each made additional attempts to talk with the AV but the AV was “initially very reluctant” and “refused” to talk about the incidents for a fear of repercussions. On December 15, 2025, during a conversation with P3, the AV “shared” that s/he was “afraid” of “getting in trouble,” “not being believed,” and/or “being blamed” for the incidents if s/he talked to P3, administrative staff persons, and/or his/her family members about “the things that happened.” After P3 provided the AV with “some reassurance” and “encouragement,” the AV told P3 about multiple incidents involving SP1 and SP2 having sexual conduct with the AV. The information the AV provided P3 was consistent with the information the AV previously told Y1 and that the AV later told P4, P6, P7, P8, P9, P11, FM1, and the MHP respectively on separate dates/times. o On December 16, 2025, P6 and an additional HR/administrative staff person (P19) contacted SP2 via a video call to talk about the concerns that were reported. SP2 recalled “being alone” with the AV during one incident on an unknown date/time after taking the AV on a break to the gym but SP2 did not remember any other incidents where s/he worked alone with the AV. Additionally, SP2 denied having an intimate/sexual relationship with the AV or engaging in any inappropriate/sexual conduct with the AV at any point. o Administrative staff did not attempt to contact and interview SP1 about the allegations because SP1 was no longer working at the facility. [Note: As of November 13, 2025, SP1 was no longer working at the facility due reasons that were not related to the allegations in this report.] · Consistent information from facility documentation and all staff persons who provided information for this investigation showed that “most” facility staff persons and youth had been “made aware” of the allegations regarding SP1 and SP2 due to the youth in cottage 3 continuously talking about the situation to others. However, there were not any “specific” incidents regarding the interactions between SP1/SP2 and the AV or any additional youth that were “actually observed, firsthand” by others at that time. However, consistent information was provided by Y1, Y3, and Y5 that each observed times when SP2 and the AV “seemed a little too close” in proximity and that the AV “frequently” left the cottage to “take breaks” with SP2. · P1 and P3 provided consistent information to this investigator that the AV “appeared discouraged,” “sad,” and “kind of just shut down” when others became aware of and talked about the incidents involving SP1 and SP2. P1 and P3 also each stated that the AV did not show “any signs” that the information s/he provided to Y1 had “any attention-seeking or ulterior motives.” “In fact,” the AV was “actually quite the opposite” in being “very visibly” “uncomfortable and upset” that Y1 told others about what happened. Additionally, P1 stated that the AV did not “partake in any gossip-like behaviors” that “some” of the other youth in cottage 3 were having at that time. P3 stated that the AV did not have a history of providing inaccurate information and/or making false allegations against other facility staff persons, teachers, family members, and/or other caregivers who s/he interacted with. · P2 said s/he regularly worked in cottage 3 during the morning and evening shifts but did not work during any overnight shifts or with SP1-SP3. Although SP2 “picked up shifts often” and worked in cottage 3 during times when P2 also worked, P2 did not directly work alongside SP2 due to the nature of the programming, the dynamics of the youth living within the cottage at that time, and splitting staff supervision between multiple youth, on multiple levels of the cottage, and/or between different activities within different areas of the campus. P2 “recalled” that the AV took “one-on-one, five-to-fifteen-minute breaks” with SP2 “pretty frequently,” at the AV’s request. However, P2 was not sure where on campus the AV and SP2 walked to during these times. P2 “knew” that the AV “often” requested to go to the gym and play volleyball and/or liked to work out so P2 assumed this was where the AV “probably” went to when taking a break with SP2. · P4, P5, and P6 provided consistent information that there were not any similar concerns regarding SP1’s or SP2’s interactions/conduct with youth prior to that time. SP1 stated that s/he worked at the facility from “early” October to November 13, 2025, during the evening and overnight shifts in cottages 2 and 4. SP1 also recalled a “few times” when s/he worked in cottage 3 during the overnight shift but did not remember “all” of the youth who lived in the cottage at that time but provided the first names of the AV, Y1, and Y5. SP1 was not aware of any concerns regarding his/her “own” interactions/conduct with youth while working at the facility and did not have any concerns with how other facility staff interacted with youth. SP1 did not remember a time when s/he worked “alone” in cottage 3 and/or with the AV. SP1 also stated that s/he “never” allowed the AV to use his/her personal phone and denied having any inappropriate or sexual interactions/conduct with the AV at any point. SP1 also denied that s/he requested the AV’s social media account information or attempt to contact the AV through social media platforms after the AV discharged from the facility. SP2 said that s/he worked at the facility from September to December 2025 during the evening shifts in cottage 4 but also “frequently” “picked up” additional shifts which included working in cottage 3 on multiple unknown dates/times. SP2 denied the allegations and provided information to this investigator that was consistent with the information SP2 provided to P6/P19. SP2 also stated that on November 1, 2025, when first working with the AV, s/he “overheard” the AV telling the other youth in the cottage that his/her family member was a lawyer and that the AV was planning to “pick on staff so [s/he] could sue [the facility].” FM1 provided information to this investigator that was consistent with the information FM1 provided to LEO2, LEO3, and the MHP. FM1 and FM2 each stated that each was not aware of the concerns until December 16, 2026, after contacting P3 about scheduling the AV’s discharge date so that the AV could be “home for the holidays.” Later that morning, P15 called and notified FM1/FM2 that the facility was looking into a report of “unfounded” allegations involving inappropriate conduct between a staff person and youth. FM1 told P15 that s/he and FM2 would drive to the facility later that afternoon to pick up the AV. FM1 and FM2 were not informed that the allegations involved the AV and were each “under the impression” that the concerns involved other youth who were living at the facility. Regarding incidents involving SP3: Y2 stated that on an unknown date/time, an unknown staff person (later determined to be SP3) made him/her “feel uncomfortable” during an incident that occurred in the living room of cottage 3. Y2 did not know SP3’s name but “remembered what the staff person looked like” and spoke to P8 about the incident at a later date/time after the incident occurred. During the incident, Y2 and the AV approached SP3 who was the only staff person working on the main level at that time and requested SP3’s assistance to obtain a cart of art supplies that was stored in an area only accessible to staff. SP3 responded by asking “something like [similar to]” “what would you do for it” in a manner that Y2 “thought” had sexual implications because of “the way [SP3] said it.” SP3 also attempted to “convince” the AV/Y2 that s/he was a “younger” age that was more “similar” to that of the AV/Y2. SP3 did not attempt to physically interact with the youth at any point during the incident and left the cottage shortly thereafter. SP3 did not have any further interactions with Y2 after this incident but briefly worked in the cottage during a later unknown date/time after this which was when Y2 told P8 about the incident. Y2 did not provide any further information about the incident to this investigator. P3-P6; the facility’s Internal Review and Incident Report dated December 11 and 12, 2025; and Y1’s Treatment Notes provided the following information: · On December 11, 2025, Y1 told P3 that there was a staff person who Y1 identified by gender (later determined to be SP3) who had inappropriate interactions with the AV and Y2 while SP3 worked in cottage 3 on an unknown date/time in. During this incident, SP3 was alone with the AV and Y2 in the living room and asked the AV and Y2 “what you ‘tryna’ do?” in a manner that had sexual implications. SP3 then tried to “convince” the AV and Y2 that s/he was younger and similar age in age to the AV/Y2. Y1 declined to provide any additional information to P3 at that time. However, Y1 told P3 that P8 was told of the incident at some point and that P8 then told SP3 not to work in the cottage. · After P3informed the facility’s administrative team about the concerns that Y1 told him/her, P6 talked to P8, the AV, Y2-Y4, and SP3 about what Y1 said. · P8 and SP3 provided consistent information to P6 that SP3’s “most recent” time working in cottage 3 was on December 9, 2025, during the overnight shift which P8 and SP2 were scheduled to work. However, SP2 was not able to start the shift on time so SP3 arrived at the cottage around 10:30 p.m. and “briefly helped” staff the cottage until SP2 arrived shortly thereafter. P8 told P6 that after SP3 left the cottage, P8 said that Y2 approached him/her and told P8 that there was a prior incident when SP3 “made [Y2] feel uncomfortable” and that Y2 “would feel safer” if SP3 did not work in cottage 3. Y2 then told P8 that on an unknown date/time, the AV and Y2 approached SP3 who was sitting in the living room and requested assistance getting art supplies. SP3 responded by asking the AV and Y2, “What they were trying to do for it? [or] What you tryna do for it,” and attempted to “convince” the AV and Y2 that SP3 was “younger” than SP3’s actual age. Y2 perceived SP3’s comments and interactions during this incident to have sexual implications but SP3 did not attempt to make any physical/sexual contact with either youth at that time. P8 said Y2 was “apprehensive about saying anything” to supervisory staff persons but also “felt uncomfortable around” SP3 so P8 told Y2 that s/he would “make sure” that SP3 was not scheduled to work in cottage 3. · The AV and Y2 each provided information to P6 that was consistent to the information provided to P6 by Y1 and P8. P6 also talked with Y3 and Y4 who were aware of the allegations but did not have first-hand information. · When P6 talked to SP3, SP3 denied these allegations and said that s/he did not have any inappropriate interactions with the AV or Y2 at that time. · According to P5 and P6, there were not any additional concerns or similar incidents involving SP3’s conduct/interactions with youth prior to this incident. SP3 stated that s/he began working at the facility during the end of October 2025 and was scheduled to work in cottage 4 during the evening shift two nights a week. SP3 “sometimes” worked additional shifts in other cottages including cottage 3. On December 9, 2025, SP3 was working the evening shift in cottage 4 when SP2 called and asked SP3 to stay about 10 more minutes to work for SP2 who was going to be a late. SP3 agreed and arrived at cottage 3 at approximately 10:45 p.m. At that time, the youth were upstairs with an unknown staff person and SP3 went into the living room and sat on the couch. Shortly after, Y2 and the AV entered the room, approached SP3, and started asking SP3 “personal,” “inappropriate,” “nonsense” questions about SP3’s age and marital status. SP3 responded that s/he did not want to answer those questions and asked the AV and Y2 to return to the upper level but they each refused to do so. The AV and Y2 continued to ask SP3 personal questions and have inappropriate interactions until SP2 arrived at the cottage shortly thereafter. SP3 stated that s/he did not tell SP2 or any other staff about these interactions and did not document the AV’s or Y2’s behaviors in the youth’s shift notes or within the Team chat as required because the SP3 was “still new [to working at the facility] and training” at that time. [Note: SP3 and administrative staff persons were not provided information by the AV, Y1, and/or Y2 about what date the incident occurred on and so staff presumed that the incident occurred on December 9, 2025. After a review of staff time sheets and shift notes, it was determined that the incident likely occurred on November 22, 2025.] Y1 provided information to this investigator regarding inappropriate comments when interacting with the AV and Y2 in the living room of cottage 3 on an unspecified date/time that was consistent with the information Y1 provided to P3. Additionally, Y1 was admitted to the facility on November 21, 2025, and stated that the incident occurred on the first or second day after s/he arrived at the facility (it was later determined that the incident occurred on November 22, 2025). Shortly after SP3 left the cottage that night, Y1 went downstairs to the main level with the other youth at that time and entered the living room where the AV and Y2 were each sitting. At some point later, the AV and Y2 told Y1 and the other youth who were present at that time about the incident with SP3. The AV/Y2 each said that they requested SP3’s assistance in obtaining a cart and that SP3 responded by asking the AV/Y2 “what they were tryna do for it” while making a gesture towards SP3’s genital area. Y1 also stated that SP3 “might” have “unzipped” his/her pants during this incident but Y1 could not remember whether this occurred but “knew” that “whatever” gesture SP3 used at that time was done in a sexual manner. The SN and the facility’s 15-Minitue Health and Safety Checks provided information that on November 22, 2025, SP3 worked in cottage 3 during the day shift with an unspecified staff person and eight youth (including the AV) who lived in cottage 3. During this shift, SP3 did not record any behavioral concerns involving the AV and/or other youth present but noted that the AV and Y2 were in the living room with SP3 when P17 arrived at the cottage to work the evening shift. Shortly thereafter, P17 noted that the AV “refused” to participate in a group activity and “whispered in the corner” with another unspecified youth throughout this activity. [Note: This information was consistent with the information that Y1 provided regarding the date and location of the incident and allegations involving SP3.] Conclusion A. Maltreatment: Consistent information showed that the AV lived at the facility from October 30 to December 16, 2025. The AV was considered to be an accurate reporter of information and did not have a history of inappropriate interactions or sexually abusive behaviors towards others. Regarding incidents involving SP1: The AV provided consistent information on different dates to multiple facility youth, facility staff persons, his/her family members, and the MHP that SP1 had sexual interactions/contact with the AV on more than one occasion. The AV also stated that, SP1 said s/he was going to give the AV “money,” “a car,” and “drugs” after the AV was discharged from the facility’s care. The AV was not aware of specific dates/times but estimated that the first incident took place after the AV first arrived at the facility and then the second incident occurred approximately one week later. Although SP1 denied the allegations and stated that s/he did not have any inappropriate or sexual interactions/contact with the AV, given that SP1 had reason to minimize his/her actions for fear of repercussions, that the AV provided consistent information at different times to multiple different people, that the AV did not have attention-seeking behaviors or a history of making false reports, and that the AV’s forensic interview with the MHP concluded that the AV was sexually assaulted, it was determined that the AV’s information was more credible. Therefore, there was a preponderance of the evidence that SP1 had sexual contact with the AV. It was determined that sexual abuse occurred (the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 - 609.3451 [criminal sexual contact in the first through fifth degree]). Regarding incidents involving SP2: The AV provided consistent information on different dates to multiple facility youth, facility staff persons, his/her family members, and the MHP that SP2 had sexual interactions/contact with the AV on more than one occasion. The AV was not aware of specific dates/times but said that the incidents occurred about once a week from mid-November to early December 2025. Although SP2 denied the allegations and stated that s/he did not have any inappropriate or sexual interactions/contact with the AV, given that SP2 had reason to minimize his/her actions for fear of repercussions, that the information provided by the AV was consistent with the facility’s documentation regarding youth shift notes and 15-minute health and safety checks, that the AV did not have attention-seeking behaviors or a history of making false reports, that the AV provided consistent information at different times to multiple different people, and that the AV’s forensic interview with the MHP concluded that the AV was sexually assaulted, it was determined that the AV’s information was more credible. Therefore, there was a preponderance of the evidence that SP2 had sexual contact with the AV. It was determined that sexual abuse occurred (the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 - 609.3451 [criminal sexual contact in the first through fifth degree]). Regarding neglect and the incident involving SP3: Facility documentation showed that on November 22, 2025, SP3 worked in cottage 3 during the day shift. Consistent information was provided that at some point during this shift, the SP3 was in the living room with the AV and Y2 while no other facility staff persons or youth were present. During that time, the AV and Y2 each provided consistent information to multiple facility staff persons that SP3 made inappropriate comments to the youth that they perceived to have sexual intent. SP3 did not make any sexual contact with the youth at that time but Y2 later told P8 that SP3 made him/her “feel uncomfortable.” SP3 denied the allegations and stated that s/he did not have any inappropriate or sexual interactions with the AV or Y2. Although the AV and Y2 provided consistent information to multiple facility staff persons that SP3 made inappropriate comments to the youth that they perceived to have sexual intent, given that SP3 denied the allegation, that there were no other concerns regarding SP3’s interactions with the youth, that SP3 did not have physical contact with the AV and/or Y2, and that if it occurred it was a single incident, there was not a preponderance of the evidence that there was a failure to supply children with necessary care or failure to protect children from serious danger to their physical or mental health. It was not determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).
B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1 and SP2 were each trained on the Reporting of Maltreatment of Minors Act and the facility’s Code of Conduct. SP1 and SP2 were each responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated sexual abuse that SP1 and SP2 were each responsible for was “recurring” and “serious” maltreatment because SP1 and SP2 each had sexual contact with the AV on multiple occasions. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and found that their policies and procedures were adequate but not followed. Staff were retrained on Maltreatment of Minors Act and when to report inappropriate staff conduct. SP2 and SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were each disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that SP2 and SP3 were each responsible for maltreatment and the disqualification of SP1 and SP2 are each subject to appeal. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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