|
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.”
Office of Inspector General Samantha.wueste@state.mn.us Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) had inappropriate interactions and sexual contact with three alleged victims (AV1, AV4, and AV5) on multiple occasions. It was also reported that SP1 provided marijuana and/or vapes containing THC to AV1, AV4, AV5, and three additional alleged victims (AV3, AV7, AV8, and AV9) on multiple occasions. During the course of the investigation, it was reported that an additional staff person (SP2) also provided “nicotine vapes” and “THC karts” to the facility youth, including AV1 and an additional youth (AV2). Allegation Two: It was reported that a staff person (SP3) became “aroused” during two separate incidents when AV2 and an additional youth (AV6) were placed in holds. Date of Incident(s): Allegation One: Multiple unknown dates between October 2025 and February 2026 Allegation Two: Multiple unknown dates between October 2025 and February 2026 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 from documentation at the facility and medical records; and through twenty-four interviews conducted with AV1, AV1’s family member (FM1), AV1’s probation officer (PO1), AV2’s social worker (SW1) who was also AV2’s legal guardian, AV3’s social worker (SW2) who was also AV3’s legal guardian, AV4’s family member (FM2), AV5’s family member (FM3), AV5’s social worker (SW3), AV5’s probation officer (PO2), AV6’s social worker (SW4) who was also AV6’s legal guardian, AV7’s family member (FM4), AV8’s social worker (SW5) who was also AV8’s legal guardian, AV9’s family member (FM5), an employee (E) of a licensed children’s residential facility where AV5 received services after his/her placement at the facility, five facility staff persons (SP1, SP2, and P2-P4), a facility staff person (SP3) who was a counselor, two facility staff persons (P10 and P11) who were therapists, a supervisory staff person (P5), and an administrative staff person (P9). Due to the nature of the allegations, SW2 refused to allow this investigator to interview AV2. AV3, AV4, and AV5 each declined to provide information for this report. Multiple attempts were made to contact AV6-AV8 and AV4’s social worker (SW6) via phone, but the attempts were not successful. However, AV2-AV5 and AV9 each provided information to members of their respective care teams and/or to the facility which was included below. SW6 also provided information to local law enforcement which was also included below. Multiple attempts were made via phone to contact and interview six additional staff persons (P1, P3, P13, and P15-P17), another supervisory staff person (P14), a facility staff person (P8) who was a nurse, and a facility staff person (P10) who was a therapist, but the attempts were not successful. However, P1, P3, P8, P10, and P13-P17 each provided information in the AV’s Miliue Notes, Nursing Notes, and/or for the facility’s Internal Review which was included below. This investigator also contacted and scheduled a phone interview with SP1’s significant other (SO). At the prearranged time, the SO did not answer the call and did not respond to subsequent attempts to reschedule an interview. This investigator contacted local law enforcement (LE) about the report and was provided with information that LE received multiple reports regarding the allegations but did not investigate further. The facility provided residential treatment services for youth ages 6 to 18 who had mental health diagnoses. The facility was a campus style setting with multiple buildings and living units. The facility had cameras mounted in the common areas, which recorded video but not audio. Initial information reported included that on an unknown date/time, an unknown staff person, who worked the night shift not on AV2’s unit, had sexual contact with AV2 including sexual penetration. A physical description of the staff was provided and then compared to staff persons who worked the night shift during AV2’s placement. Video footage and facility documentation was then reviewed and compared to the information provided by AV2, but there was not a staff person/incident that was identified to match the details provided by AV2. In addition, AV2 was unable to be interviewed regarding the allegation. Therefore, the allegation was not investigated further. AV1-AV9 each lived in the Cherbourg unit during their placements at the facility. The Cherbourg unit had two levels and was able to house/support up to 15 youth. The main level of the unit contained a secured entrance, a large foyer, a living room, a dining area, five youth bedrooms, and two shared bathrooms. The upper level of the unit contained two youth bedrooms and a shared bathroom. The facility maintained a file for each youth that contained admission paperwork and ongoing care information including screenings, assessments, and treatment plans, which included the following information: · AV1 enjoyed listening to music, outdoor activities, and spending time with his/her family members and friends. AV1’s diagnoses included unspecified neurodevelopmental disorder, oppositional defiant and conduct disorder, anxiety disorder, antisocial personality including narcissistic traits and histrionic features, and cannabis use disorder. AV1 had a history of emotional dysregulation, impulsivity, "unsafe" decision making, providing inaccurate/false information, substance abuse (marijuana and nicotine/vape), and engaging in “risky” behaviors to acquire/use substances. AV1 was vulnerable to maltreatment and had a history of being sexually abused and exploited by others. AV1 lived at the facility between October 2, 2025, and April 17, 2026, and was 15 years old. · AV2 enjoyed playing basketball, drawing, and staying active. AV2's diagnoses included disruptive mood dysregulation disorder; unspecified disruptive, impulse-control and conduct disorder; other specified trauma and stressor-related disorder; moderate and cyclothymic disorder; cannabis use disorder; tobacco use disorder; and emergent histrionic, narcissistic, antisocial and borderline personality features. AV2 had a history of emotional dysregulation, suicidal ideations, impulsivity, manipulative behaviors, leaving his/her residence without the supervision of caregivers, and substance abuse. AV2 was vulnerable to maltreatment and had a history of being sexually abused. AV2 lived at the facility between January 15 and April 21, 2026, and was 17 years old. · AV3 enjoyed listening to music, watching T.V., and drawing. AV3 was diagnosed with bipolar disorder 1, major depressive disorder, and oppositional defiant disorder, and was being monitored for borderline personality disorder. AV3 had a history of emotional dysregulation, self-injurious behaviors, suicidal ideations, inappropriate interactions with others, and making false accusations. AV3 was vulnerable to maltreatment and had “difficulties” with having a “positive body image” and building healthy relationships with others. There was no information that AV3 had a history of substance use. AV3 lived at the facility between June 6, 2025, and March 11, 2026, and was 16 years old. · AV4 enjoyed watching T.V., outdoor activities, and spending time with his/her family members. AV4's diagnoses included autism spectrum disorder, major depressive disorder with recurrent severe psychotic symptoms, generalized anxiety disorder, disruptive mood dysregulation disorder, and posttraumatic stress disorder (PTSD). AV4 had a history of self-injurious behaviors, suicidal ideations, leaving his/her residence without the supervision of caregivers, hyperarousal, and having sexual/inappropriate interactions with others. AV4 also had an “unstable past life,” with a history of sexual abuse, neglect, and abandonment. AV4 was vulnerable to maltreatment and “struggled” with “identity issues,” low self-esteem, and dissociation. There was no information that AV4 had a history of providing inaccurate information or with substance abuse, but s/he was previously prescribed medical cannabis. AV4 lived at the facility between May 30, 2025, and March 20, 2026. AV4 was 16 years old at the time of admission and 17 years old upon his/her discharge from the facility. · AV5 enjoyed drawing, outdoor activities, and spending time with his/her family members and friends. AV5's diagnoses included unspecified adjustment disorder, disruptive mood dysregulation disorder, attention-deficit hyperactivity disorder, fetal alcohol spectrum disorder, major depressive disorder, unspecified impulse control and conduct disorder, and scoliosis. AV5 “struggled” with “identity issues” and had a history of emotional dysregulation, self-injurious behaviors, impulsivity, "unsafe" decision making, attention-seeking behaviors, and providing inaccurate/false information. AV5 did not have a known history of using substances. Due to a “desire to please” others, AV5 was “easily manipulated” and “struggled” with having “appropriate” boundaries/interactions with others. AV5 was vulnerable to maltreatment and had a history of abuse and neglect during infancy. AV5 lived at the facility between November 17, 2025, and January 30, 2026. AV5 was 14 years old at the time of admission and 15 years old upon his/her discharge from the facility. · AV6 enjoyed crocheting, singing, and playing the guitar. AV6's diagnoses included depressive disorder, generalized anxiety disorder, reactive attachment disorder, posttraumatic stress disorder, and neurodevelopmental disorder. AV6 had a history of emotional dysregulation, self-injurious behaviors that resulted in multiple hospitalizations, impulsivity, "unsafe" decision making, providing inaccurate/false information, leaving his/her residence without the supervision of caregivers, and substance abuse (marijuana, nicotine, and alcohol). AV6 was vulnerable to maltreatment and had a history of physical/sexual abuse and homelessness. AV6 lived at the facility between February 12 and August 31, 2026, and was 15 years old at the time of the incident. · AV7 enjoyed listening to music, outdoor activities, and spending time with his/her family members and friends. AV7's diagnoses included depressive disorder, unspecified conduct disorder, and substance abuse disorder. AV7 was vulnerable to maltreatment and had a history of abuse. AV7 was 16 years old at the time of the incident. · AV8 enjoyed watching T.V., participating in athletic activities, and spending time with his/her family members. AV8's diagnoses included major depressive disorder, generalized anxiety disorder, and unspecified conduct disorder. AV8 had a history of emotional dysregulation, self-injurious behaviors, impulsivity, "unsafe" decision making, leaving his/her residence without the supervision of caregivers, and substance abuse. AV8 was vulnerable to maltreatment and had a history of abuse. AV8 was 16 years old at the time of the incident. · AV9 enjoyed listening to music, watching T.V., and spending time with his/her family members and friends. AV9’s diagnoses included depressive disorder and posttraumatic stress disorder. AV9 had a history of emotional dysregulation, substance abuse, "unsafe" decision making, and providing inaccurate/false information. AV3 was vulnerable to maltreatment and had a history of abuse and neglect. AV9 lived at the facility sometime between October 1, 2025, and January 25, 2026, and was 15 years old at the time of the incident. The facility’s Residential Intervention Staff Handbook stated that staff were to keep youth emotionally and physically safe. Staff were responsible for upholding a youth’s rights which included rights to positive and proactive adult guidance, support, and supervision; to courteous and respectful treatment; and to be free from abuse and harassment. Staff were to encourage youth to follow the facility’s expectations by building positive relationships, role modeling, coaching, teaching, and using collaborative problem solving with youth. Staff were responsible for their own behavior/choices and were to model the facility’s values of “honesty” and “accountability.” The facility’s Drug Free Workplace policy “prohibited” staff from “being under the influence” or “engaging in the unlawful manufacture, possession, distribution, dispensation, sale, purchase, or use” of a controlled substance, drugs, and/or alcohol while on company business, providing services, using company vehicles or on company property. The facility’s Handle with Care policy stated the following: · The facility served high-risk and emotionally dysregulated youth, who might display physically aggressive and harmful behaviors toward themselves and others. The use of physical holds might be a necessary intervention to keep youth and staff safe from physical harm. · Physical hold techniques included a one-person escort, where the staff stood behind the youth with their chest close, elbows under elbows, fingertips and wrists pointed straight up, and then the staff walked the youth forward or backward. · “Holding youth in uncomfortable or awkward positions as well as arm twisting, arms held high behind the back, hair pulling, or extensive squeezing of the youth is not acceptable or tolerated. The youth must always be treated respectfully throughout the physical hold procedure.” Facility documentation showed that SP1-SP3 and P1-P17 received training on the facility’s policies and procedures including the Residential Intervention Staff Handbook, Drug Free Workplace, and responding to incidents involving a youth’s behaviors; and the Reporting of Maltreatment of Minors Act prior to the incidents. Allegation One: It was reported that SP1 had inappropriate interactions and sexual contact with AV1, AV4, and AV5 on multiple occasions. It was also reported that SP1 provided marijuana and/or vapes containing THC to AV1, AV3, AV4, AV5, AV7, AV8, and AV9 on multiple occasions. During the course of the investigation, it was reported that SP2 also provided “nicotine vapes” and “THC karts” to the facility youth, including AV1 and AV2. Regarding SP1 AV1 provided the following consistent information on separate dates to P8, FM1, PO1, and this investigator: · On October 2, 2025, AV1 moved into the facility and was “well-liked” by “most” facility staff persons, including SP1. About “a month or so” later, SP1 told AV1 that s/he was SP1’s “new favorite” youth. Prior to this, AV7 had been SP1’s “known favorite” for a “long time.” AV1 described that “being a staff favorite” meant AV1 received “special privileges” from staff (including from SP1) and that AV1 was “allowed” to do and/or “get away with things” that other youth were not permitted to. · Throughout AV1’s placement at the facility, SP1 had inappropriate interactions/sexual contact with multiple youth who lived in the Cherbourg unit (including AV1, AV4, and AV5) on multiple occasions during times when SP1 worked the facility’s evening/morning shifts. The incidents also occurred when youth were alone with SP1 and within areas of the facility that were not monitored by surveillance cameras, which included areas of the living unit (including youth bedrooms) and a gym closet in the school building. AV1 did not recall dates/times of any incident but said that they started occurring about three weeks after AV1 arrived at the facility and continued on a weekly basis (“sometimes up to” five times a week) until mid-February 2026 when SP1 no longer worked at the facility. AV1 estimated that SP1 engaged in sexual conduct towards AV1 “at least, if not over, 50 times.” · AV1 stated that there were multiple, ongoing incidents where SP1 entered AV1’s bedroom and “sexually assaulted” him/her. AV1 further described “sexual assault” to include times when SP1 “grabbed” or “slapped” AV1’s buttocks, touched AV1’s breasts, and touched or “rubbed” AV1’s genital area. [Note: The use of the word breasts should not be used as an indicator of the gender and/or genitalia of the persons involved in this investigation.] AV1 did not recall whether SP1’s “touches” were over or under AV1’s clothing and stated that his/her mind “might have just blocked that out.” AV1 also stated that there were additional and ongoing incidents where SP1 talked to AV1 about inappropriate/sexual topics that relating to facility youth or about SP1’s personal “sex life” which included SP1’s “freaky” sexual preferences and interests. On one occasion, SP1 said that AV1 had a “perfect body to be a stripper” and “would make [a lot of money]” in that line of work. Additionally, on multiple occasions SP1 “admitted” his/her attraction towards AV5 and AV7 and talked about possible scenarios of how SP1 could “fuck” each of these youth while AV5/AV7 lived at the facility. · AV1 stated that on multiple occasions SP1 also engaged in inappropriate interactions/sexual conduct with AV4 and AV5 that was similar to how SP1 interacted/behaved towards AV1. Prior to AV5’s placement at the facility (November 17, 2025), AV4 told his/her peers that SP1 and AV4 were “dating.” However, approximately two weeks after AV5 arrived at the facility, SP1 became “less interested” in AV4 and “more focused” on pursuing an intimate relationship with AV5, causing AV4 to become “jealous” of the “attention” AV5 received from SP1. At the time, AV4 and AV5 were roommates but AV5 was later reassigned to share a bedroom with a different youth (Y1). At some point after this, Y1 talked to other youth in the unit (including AV1) about multiple occasions when SP1 entered Y1’s and AV5’s bedroom at night to engage in “sexual activities” with AV5. During these times, Y1 said that SP1 “crawled into” AV5’s bed and then Y1 could “hear” AV5 “moaning” while SP1 “touched and kissed” AV5 for an unspecified amount of time. SP1 and AV5 also provided similar information to AV1 about these incidents, which included SP1 touching AV5’s intimate areas over and under AV5’s clothing. AV1 was not aware whether SP1 and AV5 had sexual intercourse but stated that s/he “knew for sure” that SP1 had digitally penetrated AV5 on multiple occasions because SP1 “admitted it” and AV5 “openly” talked about it with AV1. · SP1 and AV5 each “trusted” and talked with AV1 “pretty frequently” about personal matters that included SP1’s/AV5’s relationship. On two separate occasions, AV1 stated that s/he saw SP1 “spank” and “grab” AV5’s buttocks during times when other youth were present. There was also an incident in January 2026 when SP1 had sexual contact with AV5 in a gymnasium closet. During the incident, SP1 entered the closet with AV5 for an unspecified amount of time while “some” other youth (including AV1 and Y1) remained nearby within the main area of the gym. After SP1 and AV5 exited the closet, AV5 appeared “all giddy” and told AV1/Y1 that SP1 “kissed” and “touched” AV5. · On another occasion, SP1 gave AV5 his/her personal phone which AV5 then took into the bathroom and used to take “nude” photos of him/herself for SP1. SP1 then showed the photos of AV5 to the SO, who was aware of and “accepting” of SP1’s and AV5’s intimate relationship. At some point after this, SP1 gave AV5 letters written by the SO requesting that AV5 partake in a “threesome” with the SO and SP1 and SP1 gave AV5 his/her phone number to contact SP1. SP1 and the SO later “invited” AV5 to come live with them and be in a polyamorous relationship with SP1 and the SO after AV5 completed treatment. Prior to AV5 being discharged from the facility (on January 30, 2026) and moving to a different residential setting, SP1 provided AV5 with a mobile phone so that AV5 could maintain contact and a relationship with SP1 outside the facility. During some time in February 2026, SP1 “came into work all excited” and told AV1 that AV5 contacted SP1 from his/her new facility. · At the time the incidents occurred, AV1 did not tell “anyone” about how SP1 interacted with the youth for multiple reasons, including that AV1 did not want to “make a scene,” did not “know” whether s/he would be “believed,” and did not want to be retaliated against while completing the rest of his/her treatment. SP1 also “regularly” provided AV1 with “free marijuana” which was AV1’s “main [source/access] to getting high” while living at the facility. Therefore, AV1 also did not want to “say anything” that led to SP1 “getting in trouble” or being “mad” at AV1, which then “might” cause AV1 to “lose the perks” of SP1 “liking/trusting” him/her. · AV1 stated that on an ongoing basis SP1 allowed “many” of the facility’s youth to “regularly” take “hits” from SP1’s personal “weed cart” (cannabis vape cartridge) that included but was not limited to AV1, AV3, AV4, AV5, AV7, AV9, and two additional youth (Y2 and Y3). Since AV1 was SP1’s “favorite,” SP1 also allowed AV1 to “actually and like physically” take SP1’s cart into AV1’s bedroom and/or “hold onto it” until AV1 finished using the cart and returned it to SP1. AV1 was not aware of any times when SP1 used his/her cart alongside or in front of the youth. But there were multiple occasions when SP1 was working and “disappeared for a bit,” and later returned to the unit showing “obvious signs” of being high on marijuana. · At some point in February 2026, SP1 “randomly stopped showing up” to work at the facility, with staff informing the youth that SP1 was a “no call, no show” for unknown reasons. A little over a month later, AV1 saw SP1 in the community and talked with him/her. SP1 said that s/he took voluntary time off to focus on his/her family but “would try” to return to work in April 2026. AV1 returned to the facility later that day and “started thinking hard” about what SP1 said, how SP1’s behaviors were “kinda fucking up a lot of the kids who already needed help,” and that this “cycle” with SP1 would continue unless “someone” said something. Shortly after this around the first/second week of April, AV1 walked into the nurse’s office and “just blurted it all out,” telling P8 about the incidents involving SP1. Shortly after this, P11 and AV1 each called and talked to FM1 about “some” of the allegations in this report, causing FM1’s concern for AV1’s health/safety. FM1 then notified P11 and P9 that s/he was “taking [AV1] home” and AV1 was discharged from the facility. · AV1 stated that for “months” after this continuing throughout the summer, SP1 attempted to contact “many” of the facility youth through social media platforms. AV1 then showed his/her phone to this investigator, opened various social media applications such as TikTok and Instagram, and showed this investigator various examples of accounts where SP1 and facility youth “followed” each other, including multiple platforms where SP1 “followed” and/or was “friends” with AV5, AV7, and AV8. FM1 and PO1 each stated that they were aware of the allegations and each stated that they “believed” that AV1 was being “truthful” and accurate in the information that was provided about the incidents. During FM5’s phone call with this investigator, FM5 declined to allow this investigator to interview or talk directly with AV9 because AV9 was already talking to his/her therapist and FM5 about the allegations. FM5 then stated that AV9 was present at the call and that FM5 would relay the questions to AV9 and then FM5 would relay AV9’s response. During the call, this investigator heard a voice in the background responding to questions but the responses were inaudible but then relayed by FM5. FM5 provided the following information: · AV9 told FM5 that on multiple occasions SP1 “messed around” with AV1, AV4, AV5, and AV7. AV9 further described “messing around” to include times when SP1 “inappropriately touched” and/or had sexual contact with youth. SP1 also “messed around” with additional youth who lived at the facility during AV9’s placement but AV9 did not recall their names. AV9 then denied that SP1 had any sexual contact with him/her. AV9 also said that on multiple occasions SP1 allowed multiple youth (including AV9) to “take hits” from SP1’s marijuana cartridge. · FM5 stated that s/he was not aware of the incidents until s/he had talked with AV9, SW6, and AV9’s mental healthcare provider during conversations that occurred “right after” receiving an initial phone call from this investigator notifying FM5 about this report. FM5 remembered AV9 mentioning “some” of the allegations in this report during the beginning of January 2026 that were also reported to SW6, the facility, and the Department of Human Services (DHS) at that time. However, AV9 did not provide any dates/times of any of the incidents and/or any names of facility staff/youth involved. “Everything” that AV9 reported at that time “seemed to just be dismissed” because of the lack of information coupled with AV9’s history of providing inaccurate information and other incidents AV9 was involved in around that same time. [NOTE: On January 6, 2026, the DHS received a report that an unidentified staff person was providing vapes to unidentified facility youth on unknown dates/times. At that time, there was no additional information and/or details provided or available so the allegation was not investigated further at that time.] The following consistent information was provided by FM4 during an interview with this investigator and from information SW6 provided to LE: · On March 20, 2026, AV4 moved into FM4’s residence after being discharged from the facility “earlier” than “planned/scheduled” for reasons that were not “clearly” specified to FM4 or SW6 at that time. · On April 23, 2026, P9 called and notified FM4 of the allegations and requested to talk to AV4, to which FM4 and AV4 then agreed to. During the call, AV4 initially “struggled” in being “forthcoming” talking about the situation with P9/FM4. However, FM4 “picked up on” AV4’s nonverbal cues of “discomfort” and provided AV4 with reassurance. AV4 then “began to open up” about what happened and talked about the incidents with SP1. AV4 said that SP1 had sexual contact with AV4 and AV5 that included multiple incidents when AV4/AV5 were each sleeping and each woke to SP1 “touching” their genital area. SP1 also “touched” AV4’s chest over his/her clothing and AV4’s neck. During one incident, SP1 “choked” AV4 because SP1 “knew” that this was a “[sexual] kink” of AV4. AV5 “wanted” to be in a “relationship” with SP1 and the SO was “ok with it.” AV4 “admitted” that s/he was “jealous” of the “attention” that SP1 gave AV5. AV4 also said that on multiple occasions SP1 gave youth (including AV4) “hits” of marijuana using SP1’s personal vape pen. · After the call with P9, FM4 called and informed SW6. On April 30, 2026, SW6 met with AV4 at FM4’s residence and talked with AV4 about the incidents. AV4 provided information to SW6 that was consistent to the information that AV4 provided to P9 and FM4. · FM4 stated that AV4 was “absolutely one hundred percent telling the truth about what happened” which was “very evident” in the manner of how AV4 “causally but emotionally” talked about this situation and his/her feelings. P8, P9, and P11, and facility documentation, including the Internal Review, provided the following information: · On April 10, 2026, during the evening, AV1 came to the nurse’s office where P8 was working and talked with P8. During the conversation, AV1 provided information to P8 that was consistent to the information that AV1 later provided to FM1, PO1, and this investigator. V1 also told P8 that there were multiple incidents when SP1 “groped” AV1’s buttocks and chest, “sucked on” AV1’s neck and chest, and digitally penetrated AV1. AV1 also said that multiple times SP1 had inappropriate interactions/sexual contact with AV4 and AV5. · After talking to AV1, P8 completed an incident report and on April 13, 2026, supervisory/administrative staff persons started an internal review including interviewing facility staff, youth and family members of the youth. The Internal Review provided the following information: o P9 talked to a youth (Y1) about the allegations. Y1 told P9 that AV4 and AV5 each had SP1’s personal phone number and AV4 told youth, including Y1, that s/he was “dating” SP1 “for a while.” Y1 provided information that was consistent to the information AV1 provided about SP1’s interactions with AV5. Y1 also said that on an unknown date/time s/he saw SP1 and AV5 go into the gym closet together for an unspecified amount of time. After SP1/AV5 exited the closet, AV5 said that SP1 kissed him/her and then later AV5 showed Y1 letters written by the SO. AV5 also talked about incidents where SP1 woke AV5 by “rubbing” AV5’s genital area but did not specify whether this was over/under clothing. [Note: During Y1’s conversation with P9, Y1 also said that P15 expressed concerns about SP1’s interactions with another youth (AV7). However, there was no additional information obtained to support this so the allegation was not included in this report.] o On April 23, 2026, P9 called and notified FM4 of the allegations and requested to talk to AV4, to which FM4 and AV4 then agreed to. AV4 provided information that was consistent to the information detailed above (to the information provided by AV1, FM1/PO1, AV9/FM5, and FM4/SW6, and that Y1 provided to P11) that on multiple occasions SP1 had sexual contact with AV4 and AV5. AV4 also said that on multiple occasions SP1 gave youth (including AV4) “hits” of marijuana using SP1’s personal vape pen. o After P9 talked with AV4, P9 called and informed the E about the allegations and asked the E to talk with AV5 which the E agreed to. [Note: The E was an administrative employee who worked at a licensed youth shelter operated by the same license holder as the facility and where AV5 was residing at that time.] The next day (April 24, 2026), the E notified P9 that AV5 talked with the E and that AV5 provided consistent information to what other facility youth previously reported to P8/P9 regarding the incidents involving SP1. AV5 said that on multiple occasions SP1 had sexual contact with AV4 and AV5 and provided the youth (including AV5) with marijuana. o Because at this point, SP1 no longer worked at the facility, administrative staff did not contact and/or interview SP1 about the allegations. [Note: As of February 13, 2026, SP1 no longer worked at the facility for reasons unrelated to this report.] o P9 also talked with two additional youth who lived in the Cherbourg unit. One youth stated that s/he was not aware of the allegations and the other youth stated s/he did not have similar interactions with SP1 and that AV1 and Y1 were providing false information. [Note: It was later determined that this youth had interpersonal conflicts with some of the other youth, including AV1, because the youth wanted to fight others.] o P9-P11 provided consistent information that prior to AV1 telling P8, supervisory/administrative staff persons were not aware of concerns involving SP1 having sexual contact with youth and/or providing youth with vapes nicotine or THC. SP1 had multiple incidents of “corrective action” regarding “poor boundaries” with the youth including SP1 using his/her personal finances to purchase a youth an MP3 player, purchasing food items for the youth, “walking the circle” with the youth after being informed not to do so by other facility staff persons and supervisory staff, and “promising” the youth that s/he would come to the facility on days that SP1 was not scheduled to work. o P8 told P9 that another youth disclosed similar information to P8 that SP1 allowed the youth to use SP1’s vape. However, no further information was provided to P8 about these incidents and SP1 was no longer working at the facility at that time. SW3 stated that s/he was aware of the allegations at a “surface level” from information that was provided by AV3. On April 28, 2026, SW3 met with AV3 regarding AV3’s schooling and case management. During the meeting, AV3 “briefly” talked about his/her placement at the facility and told SW3 that SP1 provided the facility youth (including AV3) with “free weed” on multiple occasions. AV3 said that s/he did not want SP1 to “get in trouble” and declined to provide any further information about the incidents to SW3 at that time. SW3 was not able to provide any additional information regarding the allegations. FM3, SW3, and PO2 each stated that s/he was not aware of the allegations in this report. FM3 and PO2 provided consistent information that after AV5 was discharged from the facility, AV5 was placed into two separate emergency youth shelters (each licensed by the DHS) while waiting for admission into a hospital’s residential treatment program that was scheduled for late July 2026. [Note: The second emergency shelter that AV5 resided was also operated by the same license holder as the facility.] AV5 had “adamantly” communicated multiple times to FM3 and PO2 that upon completion of the hospital’s treatment program, AV5 would be moving into an unspecified residence with a person in the community who FM3 and PO2 were each unfamiliar with and have not met. FM3 provided the name of the person which this investigator was able to determine as the SO. PO2 also told this investigator about a "recent" incident involving AV5 that occurred at one of the residential settings where AV5 was temporarily placed while waiting for admission into a hospital's treatment program. During this incident, AV5 and two other youth who lived with AV5 left the residence without the knowledge/supervision of their caregivers. The three youth were then picked up by a community person who AV5 was "familiar with" but who was an unknown person to AV5's care team, including to PO2. The person then drove the youth away from the residence to an unknown location where the youth, including AV5, were sexually exploited. PO2 then provided the first name and some physical/descriptive features of the unknown community person which matched the name and physical/descriptive features of the SO. SP1 denied the allegations and declined to provide any further information for this investigation. FM4 and SW6 each stated that s/he was not aware of the allegations in this report and did not have any additional information to provide for this investigation. Regarding SP2 During AV1’s interview with this investigator, AV1 stated that SP2 was “known” to provide youth nicotine vapes but did not recall any specific dates/times of any incidents. AV1 stated that on one occasion, SP2 purchased and gave AV1 and AV3 a vape to share. AV1 did not “ever really” consider whether this was a “big deal” because it was “just nicotine.” SP2 also “promised” to buy AV1 “edibles” but then SP2 “never actually did” purchase/provide this. FM5 stated that AV9 told him/her that on multiple occasions, SP2 provided nicotine vapes to the youth, including AV9. AV9 did not provide any further information about these incidents. SW1 provided the following information: · On April 14, 2026, SW2 met with AV2 at the facility. During the visit, AV2 informed SW1 about multiple concerns including that on multiple occasions SP2 and two additional unknown staff provided the facility youth, including AV2, with “nicotine vapes” and “THC carts.” AV2 did not recall dates/times and did not provide further information about these incidents. Shortly thereafter, a meeting was held with SW1, AV2, P9, and P10 in attendance. During the meeting, AV2 provided consistent information about the incidents, including SP2 providing vapes/cartridges to youth, during two separate conversations with each P9 and P10. After the meeting and before leaving the facility, SW1 requested that AV2 was brought to a medical clinic for testing, which P10 agreed to. The next day (April 15, 2026), P10 called and informed SW1 with test results indicating that AV2 was “positive” for THC. SW1 said that there were no occasions during that timeframe when AV2 left the facility’s campus so would not have had access to THC. · SW1 stated that although AV2 had a history of providing inaccurate/false information, AV2 was consistent in the information s/he provided and SW1 “fully believed” that this information was “truthful.” SW1 stated s/he had “known/worked” with AV2 for a “long time” and AV2 was “not a good liar because [AV2] will forget [his/her] lies and not make sense fairly quickly.” However, AV2 was able to “reiterate this information three times and the information did not change or waiver. [AV2] was very factual. [S/he] knows this is not ok and it has been disturbing to [him/her].”
P9 and P10; and the facility’s Internal Review provided the following information: · On April 14, 2026, SW2 informed P9-P11 about incidents AV2 reported to him/her which included SP2 providing the youth vapes. P11 started conducting an internal review into the allegations and interviewed SP2, unspecified facility staff, and unspecified youth who SP2 “regularly” worked/interacted with. SP2 denied providing vapes to the youth and said s/he did not allow the youth to use his/her personal vape at any time. During interviews with staff persons, “all” staff each stated that they “never witnessed” SP2 providing vapes to the youth but “all had heard kids make statement that [SP2] had passed on [his/her] vapes.” · P8 and P11 were not aware of any similar prior concerns involving SP2. SP2 denied providing vapes and/or any other substances to the youth at any time. Relevant Rules and/or Statute: Minnesota Statutes, section 609.685, subdivision 1a, paragraph (a) states in part that any person 21 years of age or older who sells, gives, or otherwise furnishes tobacco, tobacco-related devices, or electronic delivery devices to a person under the age of 21 years is guilty of a petty misdemeanor for the first violation. Minnesota Statutes, section 342.09, subdivision 1, paragraph (b) states in part that an individual may not use, possess, or transport cannabis flower, cannabis products, lower-potency hemp edibles, or hemp-derived consumer products if the individual is under 21 years of age. Conclusion for Allegation One: A. Maltreatment: Regarding SP1 and alleged sexual abuse: Facility documentation and information that AV1, AV4, AV5, and Y1 each provided to respective family members, social workers, facility staff, and/or to this investigator was consistent that SP1 engaged in inappropriate interactions and/or had sexual contact with AV4 and AV5 on multiple occasions. AV1 also provided consistent information to P8, FM1, PO1, and this investigator that SP1 engaged in sexual contact with AV1 on multiple occasions. Although SP1 denied the allegations, given that SP1 had reason to minimize his/her actions for fear of repercussions, that consistent information was provided by multiple youth who had firsthand information, that multiple youth provided consistent information at different times to multiple different people, and that AV5’s contact with the SO continued after AV5 left the facility for which AV5 would likely not have known the SO but not for the SP, it was determined that AV1’s, AV4’s, AV5’s, and Y1’s information was more credible. Therefore, there was a preponderance of the evidence that SP1 had sexual contact with AV1, AV4, and AV5 on multiple occasions. 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 SP1 and alleged neglect: Facility documentation and information that AV1, AV3, AV4, AV5, AV9, and Y1 each provided to respective family members, social workers, facility staff, and/or to this investigator was consistent that SP1 gave and allowed the youth to use SP1’s marijuana vape on multiple occasions. Although SP1 denied the allegations, given that SP1 had reason to minimize his/her actions for fear of repercussions, that consistent information was provided by multiple youth who had firsthand information, and that multiple youth provided consistent information at different times to multiple different people, it was determined that AV1’s, AV3’s, AV4’s, AV5’s, AV9’s, and Y1’s information was more credible. Therefore, there was a preponderance of the evidence that SP1 provided AV1, AV3, AV4, AV5, AV7, AV8, and AV9 with products containing marijuana on multiple occasions which encouraged each to engage in illegal activity, blurred the lines of a therapeutic relationship between youth and a staff person, and was a failure to supply each with necessary care and a failure to protect each from conditions or actions that seriously endangered their physical or mental health. It was 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 and/or 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). Regarding SP2 and alleged neglect: Information that AV1, AV2, and AV9 each provided to respective family members, social workers, facility staff, and/or to this investigator was consistent SP2 allowed the youth to use SP2’s nicotine vape on multiple occasions. AV1 also told this investigator that SP2 provided his/her vape to AV3. Although SP2 denied the allegations, given that SP2 had reason to minimize his/her actions for fear of repercussions, that consistent information was provided by multiple youth who had firsthand information, and that multiple youth provided consistent information at different times to multiple different people, it was determined that AV1’s, AV2’s, and AV9’s information was more credible. Therefore, there was a preponderance of the evidence that SP2 provided AV1, AV2, AV3, and AV9 with products containing nicotine on multiple occasions which encouraged each to engage in illegal activity, blurred the lines of a therapeutic relationship between youth and a staff person, and was a failure to supply each with necessary care and a failure to protect each from conditions or actions that seriously endangered their physical or mental health. It was 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 and/or 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. Facility documentation showed that SP1 and SP2 each received training on the facility’s policies and procedures including the Residential Intervention Staff Handbook, Drug Free Workplace, and responding to incidents involving a youth’s behaviors; and on the Reporting of Maltreatment of Minors Act. SP1 was responsible for the maltreatment of AV1, AV3, AV4, AV5, AV7, AV8, and AV9. SP2 was responsible for the maltreatment of AV1, AV2, AV3, and AV9. 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 and for which SP1 was responsible was “recurring” and “serious” maltreatment because SP1 was responsible for neglect of seven youth (AV1, AV3, AV4, AV5, AV7, AV8, and AV9) on more than one occasion and sexual abuse of three youth (AV1, AV4, and AV5) on more than one occasion. It was determined that the substantiated neglect for which SP2 was responsible was “recurring” maltreatment because SP2 was responsible for neglect of four youth (AV1, AV2, AV3, and AV9) on more than one occasion. However, it did not meet the definition of serious because no youth sustained and injury that required the care of a physician. SP2 was disqualified from providing direct contact services.
Allegation Two: It was reported that SP3 became “aroused” during two separate incidents when AV2 and AV6 were placed in holds. SW1 stated that s/he met with AV2 at the facility on April 14, 2026. During the visit, AV2 informed SW1 about multiple concerns including an incident when SP3 placed AV2 into a hold shortly after AV2 arrived at the facility. AV2 told SW1 that during the hold, SP3 became “aroused” and AV2 “felt” SP3’s genital area “press against” AV2’s back. Shortly thereafter, a meeting was held between SW1, AV2, P9, and P10. AV2 then provided consistent information about this incident to P9 and P10 in separate conversations with each. SW4 stated that s/he met with AV6 at the facility on June 9, 2026. During the visit, AV6 informed SW4 about an incident when SP3 placed AV6 into a hold on June 4, 2026. AV6 told SW4 that during the hold, SP3 placed AV6 in a position where AV6 was “practically sitting on top of [SP3’s] lap,” which caused AV6 to “feel uncomfortable.” At some point shortly after this, SP3 became “aroused” and AV6 “felt” SP3’s genital area “press against” the “backside” of AV6’s body. AV6 then began to “panic” and “yelled out for help” to another unknown staff person (later determined as P6) who was present at that time. However, P6 ignored AV6’s requests for help and did not intervene or remove AV6 from the situation. After talking with AV6, SW4 left the facility. On June 13, 2026, SW4 emailed P9 about the incident and the concerns that AV6 told to SW4. On June 15, 2026, P9 responded to SW4 via email and phone call that the facility was “looking into the matter” and would “respond accordingly.” SW4 did not have any additional information to provide regarding the allegation. P8 and P9 and the facility’s Internal Reviews provided the following information:
· On April 14, 2026, SW2 told P9-P11 that AV2 said that on March 23, 2026, SP3 placed AV2 into a hold and during the hold, SP3 became "aroused." AV2 said s/he "felt" SP3's genital area against AV2's back. P8 then talked to SP3 and "all" staff persons (P13-P16) who were present at some point during the incident and "witnessed" the hold. SP3 denied the allegations and P13-P16 each stated that SP3 placed AV2 into a hold that was consistent with the facility's policies and procedures.
· P8 and P9 each stated that the incident occurred in an outdoor area where there were no cameras. Additionally, SP3 worked at the facility for ten years and at that time, there had not been any similar concerns/incidents involving SP3.
· On June 13, 2026, SW4 emailed P9 about concerns AV6 reported to him/her which included an incident on June 4, 2026, where SP3 placed AV6 into a hold. During the hold, AV6 said that SP3 became "aroused" and that AV6 "felt" SP3's genital area against AV6's back. · P9 then reviewed video footage of the incident but did not see any concerns with SP3’s actions at that time. P9 also talked with staff persons (P6 and P7) who were present at that time. P6 and P7 each denied the allegations and said that SP3 placed AV6 into a hold that was consistent with the facility’s policies and procedures. P9 then talked with SP3 who also denied the allegations. SP3 said s/he was aware of the allegations and that s/he “always” responded to youth behaviors (including AV2’s and AV6’s behaviors) in a manner that was appropriate, “professional,” and consistent with the facility’s policies and with each youth’s care plans. During times when a youth had maladaptive behaviors, staff were to attempt to “redirect” and “de-escalate” the situation. If at any point a youth’s behaviors became a “threat” to the safety of him/herself and/or to others, staff persons were to place the youth within a hold until the youth was able to “safely” regulate his/her emotions/behaviors. On unknown dates/times, SP3 “remembered” two separate incidents where s/he was involved in placing each AV2 and AV6 in a hold in response to each having escalated and unsafe behaviors. During each of these incidents, there were multiple other staff persons who were nearby witnessing and/or assisting with the situation in trying to help “calm” AV2/AV6. At the time, when SP3 “initially” placed each youth within a hold, AV2/AV6 became “more upset” and “increasingly” aggressive towards SP3 and towards other staff who were involved. “Eventually” after an unknown amount of time, AV2 and AV6 each returned to a “safer” and “calmer state of mind” at some point later during each incident, which was when SP3 “would have released” AV2/AV6 from the hold. SP3 denied “exerting unnecessary force” or engaging in a “power struggle” with either youth at any point during these incidents. SP3 also denied having “any form” of inappropriate/sexual conduct at “any” time towards AV2, AV6, and/or “any other” facility youth. The facility’s video surveillance dated June 4, 2026, was reviewed by this investigator. Although the video did not include audio and the hold was completed in an area of the room that did not fully/clearly show the entirety of the incident, this investigator did not observe any concerns with the manner in which SP3 implemented the hold of AV6 during that time. There were two other staff persons present during the incident and appeared to be talking with AV6 at various times. During the investigation, FM1 also told this investigator that s/he had concerns with how SP3 implemented restraints when placing AV1 within a hold on two separate occasions. Each incident occurred shortly after AV1 arrived at the facility, without any further incidents or similar concerns occurring for the remainder of AV1’s placement. FM1 stated that AV’s legs were “covered” in “dark” unexplained bruises that “run up and down” each of AV1’s legs. FM1 “believed” that AV1 sustained this bruising during the holds as a result of SP3’s actions. FM1 later provided photos of AV1’s injuries to this investigator which showed bruising on each of AV1’s legs, as FM1 described. AV1 stated that s/he was not aware of any incidents where SP3 was aroused or had his/her genitals touching any youth at any point, including times when youth were placed into holds by SP3. AV1 also stated that “the main complaint” regarding SP3 was “just how aggressive” SP3 was when placing youth in holds, including two incidents where SP3 placed AV1 into a hold after AV1 left the facility without the supervision of staff persons. AV1 also stated that SP3 “tended” to place youth in holds when it “wasn’t really necessary” which “probably pissed some kids off.” AV1 thought the bruising on his/her legs “looked bad,” but AV1 also stated that the bruising was “mainly” caused by times when AV1 “jumped out” of his/her bedroom window after first arriving to the facility. Conclusion for Allegation Two: Information showed that SP3 was involved in a restraint with AV2 and AV6 respectively. Although AV2 and AV6 each told their respective family members and/or social workers that SP3 was aroused and/or that his/her genitals touched their backs during the hold, given that SP3 denied the allegations, that the other staff persons who witnessed each restraint also denied the allegations and stated that each hold was consistent with the facility’s policies and procedures, that there were no other concerns regarding SP3’s interactions with the youth, there was not a preponderance of the evidence that SP3 has sexual contact with either AV2 and/or AV6. It was not 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]). 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 determined that policies and procedures were adequate and followed by SP3 and SP4, with inconclusive findings on whether incidents of maltreatment occurred involving the actions of SP1 and SP2. SP2 was retrained on facility policies and procedures relating to professionalism and boundaries. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 was 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 was responsible for maltreatment and the disqualification of 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.
|
