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STATE OF MICHIGAN

GRETCHEN WHITMER DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS ORLENE HAWKS


GOVERNOR DIRECTOR
LANSING

August 23, 2019

Theressa Nelson
My Beloved Group Home
24260 Radclift Street
Oak Park, MI 48237

RE: License #: AS630355154


Investigation #: 2019A0989068
My Beloved Group Home

Dear Ms. Nelson:

Attached is the Special Investigation Report for the above referenced facility. Due to the
violations identified in the report, a written corrective action plan is required. The
corrective action plan is due 15 days from the date of this letter and must include the
following:

 How compliance with each rule will be achieved.


 Who is directly responsible for implementing the corrective action for each
violation.
 Specific time frames for each violation as to when the correction will be
completed or implemented.
 How continuing compliance will be maintained once compliance is
achieved.
 The signature of the responsible party and a date.

A six-month provisional license is recommended. If you do not contest the issuance of a


provisional license, you must indicate so in writing; this may be included in your corrective
action plan or in a separate document. If you contest the issuance of a provisional license,
you must notify this office in writing and an administrative hearing will be scheduled. Even
if you contest the issuance of a provisional license, you must still submit an acceptable
corrective action plan.

If you desire technical assistance in addressing these issues, please feel free to contact
me. In any event, the corrective action plan is due within 15 days.

611 W. OTTAWA  P.O. BOX 30664  LANSING, MICHIGAN 48909


www.michigan.gov/lara  517-335-1980
Please review the enclosed documentation for accuracy and contact me with any
questions. In the event that I am not available and you need to speak to someone
immediately, please contact the local office at (248) 975-5053.

Sincerely,

Theresa Cipponeri, Licensing Consultant


Bureau of Community and Health Systems
4th Floor, Suite 4B
51111 Woodward Avenue
Pontiac, MI 48342
(248) 285-8590

enclosure
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
BUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT
CAUTION: THIS REPORT CONTAINS EXPLICIT LANGUAGE

I. IDENTIFYING INFORMATION
License #: AS630355154

Investigation #: 2019A0989068

Complaint Receipt Date: 07/18/2019

Investigation Initiation Date: 07/19/2019

Report Due Date: 09/16/2019

Licensee Name: My Beloved Group Home

Licensee Address: 24260 Radclift Street Oak Park, MI 48237

Licensee Telephone #: (248) 470-0063

Administrator: Theressa Nelson

Licensee Designee: Theressa Nelson

Name of Facility: My Beloved Group Home

Facility Address: 16066 Fairfax Street Southfield, MI 48075

Facility Telephone #: (248) 905-3419

Original Issuance Date: 06/17/2014

License Status: REGULAR

Effective Date: 12/17/2016

Expiration Date: 12/16/2018

Capacity: 6

Program Type: PHYSICALLY HANDICAPPED


DEVELOPMENTALLY DISABLED
MENTALLY ILL
TRAUMATICALLY BRAIN INJURED
ALZHEIMERS

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II. ALLEGATION(S)

Violation
Established?
Staff member, Jermell Johnson, punched Resident B in the face. Yes

Staff swears at the residents and speak to them in a rude and Yes
disrespectful manner.

Resident A is always dirty and not allowed to shower. No

Residents do not have clean clothes and at times have had to Yes
wear the same clothes for several days in a row.

The facility is dirty and unkempt. Yes

III. METHODOLOGY

07/18/2019 Special Investigation Intake


2019A0989068

07/18/2019 APS Referral


Received referral from Adult Protective Services (APS).

07/18/2019 Contact - Document Received


Received second complaint with additional information.

07/19/2019 Special Investigation Initiated - Telephone


Left a voicemail message for the assigned APS investigator,
Marcie Fincher, requesting a return call.

07/19/2019 Contact - Document Received


Received additional complaint information.

07/19/2019 Contact - Document Received


Received more additional complaint information.

07/19/2019 Contact - Telephone call made


Left a voicemail message for the Reporting Source (RS).

07/19/2019 Contact - Document Received


Received new allegations from the same RS.

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07/22/2019 Contact - Telephone call received
Received voicemail message from the RS, requesting a return
call.

07/23/2019 Contact - Telephone call made


Spoke to RS via telephone.

07/23/2019 Contact - Telephone call received


Received voicemail message from Ms. Fincher, requesting a
return call.

07/23/2019 Contact - Telephone call made


Left a voicemail message for Ms. Fincher, requesting a return call.

07/23/2019 Contact - Telephone call made


Left a voicemail message for the Office of Recipient Rights (ORR)
investigator, Darlita Paulding, requesting a return call.

07/24/2019 Contact - Telephone call made


Spoke to Ms. Paulding.

07/29/2019 Contact - Document Received


Received email from Ms. Paulding.

07/30/2019 Contact - Document Received


Received new allegations from same RS.

08/05/2019 Contact - Document Sent


Received email from Ms. Paulding.

08/07/2019 Contact - Face to Face


Interviewed Residents A-C at the drop-in Center in Oak Park.

08/07/2019 Contact - Face to Face


Interviewed Residents D-F and staff, Di’Angelo Carlton, at the
facility.

08/08/2019 Contact - Document Sent


Sent email to Ms. Paulding regarding my onsite inspection.

08/09/2019 Contact - Telephone call made


Spoke to Ms. Fincher.

08/09/2019 Contact - Telephone call made


Left a voicemail message for Ms. Paulding, requesting a return
call.

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08/09/2019 Contact - Telephone call made
Interviewed the Home Manager, Ken Franklin, via telephone.

08/12/2019 Contact - Telephone call made


Left a message for staff, Jermell "Koby" Johnson, requesting a
return call.

08/12/2019 Contact - Telephone call made


Interviewed staff, Kailyn Mulkey, via telephone.

08/12/2019 Contact – Telephone call received


Spoke to Ms. Paulding.

08/13/2019 Exit Conference


Attempted to hold an exit conference with the Licensee Designee,
Theressa Nelson, however, her voicemail was full and I was
unable to leave a message for her.

08/21/2019 Contact-Face to face


Scheduled a conference with Ms. Nelson, however she did not call
to cancel nor did she appear for the meeting.

ALLEGATION:

Staff member, Jermell Johnson, punched Resident B in the face.

INVESTIGATION:

On 7/23/2019, I spoke to the Reporting Source (RS) via telephone, and she stated that
staff member Jermell Johnson (the residents call him Koby), punched Resident B in the
face during an argument. The date is unknown.

On 7/24/2019, I spoke to Darlita Paulding, Office of Recipient Rights (ORR) investigator.


Ms. Paulding stated that she recently interviewed Mr. Johnson and he told her that he
and another staff member, Kailyn Mulkey, were in the living room talking about dinner.
Suddenly, he saw Resident B take off his hat, glasses, and chains he always wears and
out of nowhere, he punched Mr. Johnson in the face. Mr. Johnson stated that his first
reaction was to hit Resident B back without thinking.

On 8/7/2019, I interviewed Resident B at the Oak Park drop-in center, and he stated
that he punched Mr. Johnson in the face, so Mr. Johnson punched him back one time in
the space between his neck and his shoulder. While onsite, I interviewed Resident A
and he stated that he saw Mr. Johnson punch Resident B three times. I attempted to
interview Resident C, however, Resident C stated that he did not wish to speak with me.

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On 8/7/2019, I conducted an unannounced onsite inspection to the facility and
interviewed Residents D and F. Both stated that they did not see it, but they heard that
Mr. Johnson punched Resident B in the face. Resident D added that Mr. Johnson is
aggressive when he talks and how he acts toward them. I was unable to interview
Resident E, as he was sleeping.

On 8/9/2019, I spoke to Marcie Fincher, the assigned Adult Protective Services (APS)
investigator. Ms. Fincher stated that she interviewed Mr. Johnson and he admitted to
punching Resident B after Resident B punched him first. Resident B had no marks or
bruises on him and did not require medical treatment.

On 8/9/2019, I called the Home Manager, Ken Franklin, and spoke to him. Mr. Franklin
stated that he had no knowledge of this incident, and that he has not been at the facility
much.

On 8/12/2019, I attempted to contact Mr. Johnson via telephone, however his phone
immediately went to voicemail. I left a voicemail message requesting that he contact me
back.

On 8/12/2019, I interviewed staff, Kailyn Mulkey, via telephone. Ms. Mulkey stated that
she was on shift with Mr. Johnson when this incident happened. Resident B and Mr.
Johnson were sitting on separate couches and suddenly Resident B got up. He took off
his hat, his glasses, and the many chains that he wears around his neck and started
challenging Mr. Johnson to fight him. Mr. Johnson bent down to pick up Resident B’s
items that he had thrown on the floor, and in the process of doing so, Resident B
punched Mr. Johnson square in the face. Mr. Johnson then quickly slapped Resident B
back. Ms. Mulkey stated that she was sitting at the desk in the same room but couldn’t
see if Mr. Johnson used an open or closed fist. After that, Resident B went upstairs and
nothing further happened.

APPLICABLE RULE
R 400.14308 Resident behavior interventions prohibitions.

(1) A licensee shall not mistreat a resident and shall not


permit the administrator, direct care staff, employees,
volunteers who are under the direction of the licensee,
visitors, or other occupants of the home to mistreat a
resident. Mistreatment includes any intentional action or
omission which exposes a resident to a serious risk or
physical or emotional harm or the deliberate infliction of
pain by any means.

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ANALYSIS: Recently, without warning Resident B punched staff member,
Jermell Johnson, in the face, and Mr. Johnson hit Resident B
back. Immediately prior to this incident, Resident B had
reportedly been agitated and was trying to get Mr. Johnson to
fight him. Mr. Johnson did not engage Resident B, therefore
Resident B punched Mr. Johnson in the face. According to Mr.
Johnson, his first reaction was to punch him back.

CONCLUSION: VIOLATION ESTABLISHED

ALLEGATION:

Staff swears at the residents and speak to them in a rude and disrespectful
manner.

INVESTIGATION:

On 7/23/2019, I spoke to the Reporting Source (RS) via telephone, and she stated that
the staff at this facility swear at the residents and speak to them rudely.

On 7/24/2019, I spoke to Darlita Paulding, Office of Recipient Rights (ORR) investigator.


Ms. Paulding stated that she recently interviewed staff members, Kailyn Mulkey and
Jermell Johnson, and they stated that they may have private conversations in the facility
amongst themselves in which they use swear words, however, they have never sworn
at the residents or spoken to them in a disrespectful manner. The staff added that
Resident A frequently eavesdrops on other people’s conversations and sneaks up on
people.

On 8/7/2019, I interviewed Resident A at the Oak Park drop in center. Resident A stated
that when he tries to talk to Ms. Mulkey, she says, “I don’t give a fuck, (Resident A)”,
and “(Resident A), stop fucking around”. There was a time when another staff member,
Di’Angelo Carlton, asked Resident A if he answered the phone, and Resident A said,
“Fuck you” to him. Mr. Carlton responded by saying, “Fuck you too” right back to him.
Resident A stated that staff is just very rude and impatient toward him in general and
they yell at him whenever he asks them for something. While still onsite, I interviewed
Resident B. Resident B stated that he does not want to live at this facility anymore
because he does not feel safe with the staff. The staff are mean and swear at him and
the residents. The Home Manager, Ken Franklin, is never there and either is the owner,
Theressa Nelson. Staff does what they want. I attempted to interview Resident C,
however, Resident C stated that he did not wish to speak with me.

On 8/7/2019, I conducted an unannounced onsite inspection and interviewed Resident


D at the facility. Resident D stated that Ms. Mulkey is very violent and she swears at
them using vulgar words. While onsite, I attempted to interview Resident E, however, he
was sleeping. I interviewed Resident F, who stated that he thinks a staff member was
just fired for swearing, but he doesn’t know for sure. Resident F was ambivalent and

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stated that he doesn’t think he has heard staff swear recently. Mr. Carlton was working
at the time of my onsite inspection, and he denied swearing at the residents. Mr. Carlton
stated that he does not work with Ms. Mulkey, however, the residents tell him that she
swears directly at them and sometimes she just uses swear words around them in
general conversation with staff or when she is on the phone. Mr. Carlton further added
that Mr. Franklin does not really come here because he has had some health problems.
Ms. Nelson used to be at the facility pretty much every day, but she also has been
having some health problems, so she has not been coming to check on things in the
facility either. There isn’t really any staff oversight happening right now, since neither
Mr. Franklin nor Ms. Nelson have been coming to check on things at the facility.

APPLICABLE RULE
R 400.14308 Resident behavior interventions prohibitions.

(2) A licensee, direct care staff, the administrator, members


of the household, volunteers who are under the direction of
the licensee, employees, or any person who lives in the
home shall not do any of the following:
(f) Subject a resident to any of the following:
(ii) Verbal abuse.

ANALYSIS: Resident A stated that Ms. Mulkey swears at him, and another
staff member, Di’Angelo Carlton has told him, “Fuck you”.
Resident B stated that staff swear at the residents and he does
not want to live at this facility anymore because of the staff.
Resident D stated that Ms. Mulkey is very violent and swears at
them using vulgar words. Mr. Carlton denied ever swearing at
the residents or using swear words in general around the
residents but stated that the residents tell him that Ms. Mulkey
swears at them.
Darlita Paulding, Office of Recipient Rights (ORR) investigator,
interviewed staff members Jermell Johnson and Kailyn Mulkey,
and both denied swearing directly at the residents but stated
that they may use swear words in their private conversations. I
interviewed Ms. Mulkey, and she denied swearing at all,
especially at the residents.

CONCLUSION: VIOLATION ESTABLISHED

ALLEGATION:

Resident A is always dirty and not allowed to shower.

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INVESTIGATION:

On 7/23/2019, I spoke to the Reporting Source (RS), who stated that Resident A is
always dirty and not allowed to shower. He never told her that, she just believes this
because whenever she sees him he looks dirty.

On 8/7/2019, I interviewed Resident A at the Oak Park drop in-center. Resident A stated
that he has not been able to take a shower in three days because there is no shower
curtain in the bathroom downstairs. Something happened to the shower curtain in the
upstairs bathroom, so staff put some sort of towel or blanket to use as a curtain.
Resident A stated that he is allowed to shower whenever he wants and so is everybody
else, but there needs to be a shower curtain in the bathroom.

On 8/7/2019, I conducted an unannounced onsite inspection to the facility. I interviewed


staff, Di’Angelo Carlton, who stated that all of the residents are allowed to shower
anytime they wish. Mr. Carlton stated that Resident A does not like to shower much, but
he does not say why. Mr. Carlton stated that he works both morning and afternoon
shifts and he does not see Resident A shower often at all. Staff does encourage him to
do so and Resident A’s reluctance to shower is not something new.

On 8/12/2019, I interviewed staff, Kailyn Mulkey, via telephone. Ms. Mulkey stated that
Resident A is allowed to shower whenever he wants, however, it is very difficult to get
him to shower. Staff will prompt him. He will shower with no problem if he is having a
visitor or if there is a special occasion, however, other than that he shows no interest in
personal hygiene.

APPLICABLE RULE
R 400.14314 Resident hygiene.

(1) A licensee shall afford a resident the opportunity, and


instructions when necessary, for daily bathing and oral and
personal hygiene. A licensee shall ensure that a resident
bathes at least weekly and more often if necessary.

ANALYSIS: Resident A stated that he is allowed to shower whenever he


wants, however, there are no shower curtains on the showers
and he does not want to shower until there are shower curtains.
According to staff members Di’Angelo Carlton and Kailyn
Mulkey, Resident A has always been reluctant to shower and
this is not a new issue. Staff frequently has to prompt him to
shower.

CONCLUSION: VIOLATION NOT ESTABLISHED

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ALLEGATION:

Residents do not have clean clothes and at times have had to wear the same
clothes for several days in a row.

INVESTIGATION:

On 7/23/2019, I spoke to the Reporting Source (RS), who stated that Resident A told
her that staff never washes the resident’s clothes and as a result he frequently has to
wear the same clothes several days in a row.

On 8/7/2019, I interviewed Resident A at the Oak Park drop-in center. Resident A stated
that recently he had to wear the same clothes for three days in a row because staff do
not wash the resident’s clothing, and they wait until they are right down to their very last
piece of clothing before they notice that laundry should be done. Staff does not care
because there is no one to supervise them to make sure they are doing their jobs. While
onsite, I interviewed Resident B, who stated that he often does not have a lot of clean
clothes. Resident C did not wish to speak with me.

On 8/7/2019, I conducted an unannounced onsite inspection to the facility. I interviewed


Resident D at the home, who stated that he thinks staff washes his clothes. Resident E
was sleeping, and Resident F stated that staff washes his clothes but not often at all.
Staff will wash his clothes when he runs through all of them and is down to his last pair
of clothing. Sometimes he has to wait for clean clothes to be washed. While onsite, I
interviewed staff member, Di’Angelo Carlton. Ms. Carlton stated that staff does wash
the resident’s clothing on a regular basis. I checked the wash machine and I saw that
there was a load of clothing in there that had recently been washed.

I inspected the home in the company of Mr. Carlton. The first bedroom belonged to
Residents D and F. There were clothes in the dresser and hung in the closet. The floor
of the closet was cluttered with clothes, blankets, and other miscellaneous items. I
inspected the second bedroom, which belonged to Residents B and E. There were
clothes in piles all over the floor, and I could not tell with 100% certainty if the clothes
were clean or dirty. Mr. Carlton stated that Resident B refuses to fold his clothes or put
them away and likes to keep them all over the floor. Lastly, I inspected the third
bedroom upstairs, which belonged to Residents A and C. Both sides of the bedroom
had clothes strewn all over the floor. The clothes did not look clean, nor were they
folded or placed in any sort of orderly manner. Mr. Carlton stated that this is the way
that the residents like to keep their clothes in their bedrooms.

On 8/12/2019, I interviewed staff, Kailyn Mulkey, via telephone. Ms. Mulkey stated that
staff washes the resident’s clothes but the residents just throw them on the floor. Ms.
Mulkey added that the residents don’t really like for staff to wash their clothes.

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APPLICABLE RULE
R 400.14314 Resident hygiene.

(5) A licensee shall afford a resident with opportunities, and


instructions when necessary, to routinely launder clothing.
Clean clothing shall be available at all times.

ANALYSIS: Residents A, B, and F stated that they often do not have clean
clothes. Staff will wait until they are completely out of clean
clothing and then they will wash their clothes, and Resident A
stated that recently he had to wear the same dirty clothes three
days in a row because he had no clean clothes.

CONCLUSION: VIOLATION ESTABLISHED

ALLEGATION:

The facility is dirty and unkempt.

INVESTIGATION:

On 7/23/2019, I spoke to the Reporting Source (RS). According to the RS, the home is
“filthy”, “dirty”, and just not set up the way an Adult Foster Care facility should be set up.
She could not exactly explain what was wrong with it, and just simply stated that it looks
“ghetto”, way past shabby and run-down. The carpets are stained, paint is peeling, and
it is not kept up. The RS stated that I would have to see it for myself to understand.

On 8/7/2019, I conducted an unannounced onsite inspection to the facility. I inspected


the home in the company of staff, Di’Angelo Carlton. I inspected all three bedrooms and
saw clothing strewn all over the floors. The first bedroom had one bed with no sheets or
linens on it, and the pillow was completely flat with barely any stuffing left in it. The other
bed in the bedroom had only a bottom sheet and nothing else on it. In the second
bedroom, one of the beds had only a plastic covering with no linens, sheets, or blankets
on it. The pillow was flat and the white pillowcase was stained with brown spots. The
second bed in the bedroom had only a bottom sheet and a flat pillow with barely any
stuffing in it to make it comfortable to rest one’s head on. Going up the stairs to the third
bedroom I observed a broken handrail. On the landing of the stairs were stored items
that contributed to the clutter of the facility. Mr. Carlton stated that he thought that the
items may belong to a former resident, but he was not certain. Upstairs, the third
bedroom was cluttered and difficult to walk through, as there were clothes and random
items strewn all over the floor. A blanket and a pillow were on each of the beds and
nothing else. The pillows on these beds did not appear to be particularly comfortable, as
they were flat as well but they looked better than the other pillows in the facility. The
carpet in the third bedroom was worn and had several stains on it. The wall and molding
had some type of red substance that appeared to be paint splashed on it. None of the

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beds were made nor was there any method of organization that presented a clean, well
maintained facility.

I inspected the laundry room and found a door with a missing slat that needed to be
repaired/replaced, and there were piles of clothing and random items everywhere in the
laundry room.

The downstairs bathroom had no shower curtain or any other means of covering the
combination tub/shower. The upstairs bathroom had what looked like a white towel or
blanket knotted over the shower curtain frame where a shower curtain is supposed to
be hung.

I went outside and walked around the perimeter of the facility. The front yard
landscaping had many long weeds and an entire section of the landscaping next to the
facility was just dirt that had filled in with weeds. In the backyard, there were a bunch of
tangled wires laying on the roof, and it was not immediately evident as to what the wires
were for or where they led. The backyard was overgrown with weeds and had an old,
unsightly basketball hoop off to the side, an old rusty barbecue, two boxes built of wood
on the grass that had nothing growing in them but weeds, and other large, unidentifiable
objects on the lawn that didn’t appear as if they served any purpose. The bushes were
overgrown and in need of pruning. The door on the detached garage was in need of
new paint and had a hole in one of the sides of it.

The inside and outside of the facility appeared to be worn, untidy, and poorly
maintained.

Mr. Carlton stated that since the Home Manager, Ken Franklin, and the owner,
Theressa Nelson, have stopped coming to check on things at the facility there has been
no staff oversight and no one is really in chare of running the facility. Things have
started to fall apart and staff routines/responsibilities have become lax.

On 8/9/2019, I called the Home Manager, Ken Franklin, and spoke to him. Mr. Franklin
stated that he had no knowledge of the many things that have been happening in the
facility, as he has not been at the facility much. Mr. Franklin stated that both he and the
owner, Theressa Nelson, have had medical problems which have kept them from
overseeing the facility. Mr. Franklin stated that he is returning back to the facility within
the next few days and that Ms. Nelson is also aware of the concerns that I observed
when I came out to the facility and she wants to get the issues rectified immediately. Mr.
Franklin stated that when they both return they are going to get things back in order so
the facility can be ran properly again and kept up as it is required to be.

On 8/12/2019, I interviewed staff member, Kailyn Mulkey, who stated that Mr. Franklin
and Ms. Nelson have not been to the facility in months due to health problems. As a
result, staff have been doing what they want, as there hasn’t been any supervision.

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APPLICABLE RULE
R 400.14403 Maintenance of premises.

(1) A home shall be constructed, arranged, and maintained


to provide adequately for the health, safety, and well-being
of occupants.

ANALYSIS: The home is in need of maintenance in several areas in order to


keep it looking tidy and well maintained. On 8/7/2019, I
observed the resident’s bedrooms to be cluttered and
disorganized, the laundry room door is in need of
repair/replacement, and both bathrooms need shower curtains.
In some areas the carpet is worn and has stains on it.

CONCLUSION: VIOLATION ESTABLISHED

APPLICABLE RULE
R 400.14403 Maintenance of premises.

(13) A yard area shall be kept reasonably free from all


hazards, nuisances, refuse, and litter.

ANALYSIS: On 8/7/2019, I observed the landscaping in both the front and


backyard and saw that it is in need of maintenance. Long weeds
are growing and the bushes need to be pruned. The backyard
has several objects in it that need to be removed, and the door
on the detached garage is in need of new paint and has a hole
in one of the sides of it.

CONCLUSION: VIOLATION ESTABLISHED

APPLICABLE RULE
R 400.14403 Maintenance of premises.

(8) Stairways shall have sturdy and securely fastened


handrails. The handrails shall be not less than 30, nor more
than 34, inches above the upper surface of the tread. All
exterior and interior stairways and ramps shall have
handrails on the open sides. All porches and decks that
are 8 inches or more above grade shall also have handrails
on the open sides.

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ANALYSIS: On 8/7/2019, I observed the handrail going upstairs to the third
bedroom needs to be repaired, as it has become detached from
the wall on one end, rendering it useless and making the stairs a
safety hazard.

CONCLUSION: VIOLATION ESTABLISHED

APPLICABLE RULE
R 400.14411 Linens.

(1) A licensee shall provide clean bedding that is in good


condition. The bedding shall include 2 sheets, a pillow
case, a minimum of 1 blanket, and a bedspread for each
bed. Bed linens shall be changed and laundered at least
once a week or more often if soiled.

ANALYSIS: On 8/7/2019, I saw that none of the beds were properly made
up, and none of them had two sheets on them or a bedspread.
Some beds only had a blanket, and two of the beds I observed
had no linens on them whatsoever.

CONCLUSION: VIOLATION ESTABLISHED

APPLICABLE RULE
R 400.14411 Linens.

(2) A licensee shall provide at least 1 standard bed pillow


that is comfortable, clean, and in good condition for each
resident bed.

ANALYSIS: On 8/7/2019, I observed three separate pillows to be almost flat


with no stuffing in them, and one of the pillowcases had brown
stains on it.

CONCLUSION: VIOLATION ESTABLISHED

ADDITIONAL FINDINGS:

INVESTIGATION:

On 8/7/2019, I interviewed Resident B and Resident F, who stated that the Licensee
Designee, Theressa Nelson, and the Home Manager, Ken Franklin, are never around
anymore to keep things in order.

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On 8/7/2019, I interviewed staff, Di’Angelo Carlton stated that things have started to fall
apart since Mr. Franklin and Ms. Nelson have stopped coming to check on things at the
facility and there has been no staff oversight.

On 8/9/2019, I called Mr. Franklin and he had no knowledge of the many things that
have been happening in the facility, as he has not been at the facility much. He is
returning back to work at the facility very soon and will be working hard to get the facility
to where it needs to be.

On 8/13/2019, I attempted to hold an exit conference with the Licensee Designee,


Theressa Nelson, however, her voicemail was full and I was unable to leave a message
for her. On 8/21/2019, a conference/meeting was scheduled with Ms. Nelson and staff
at the Pontiac office to discuss the violations in this report. However, Ms. Nelson did
not call to cancel nor did she appear for the meeting.

APPLICABLE RULE
R 400.15201 Qualifications of administrator, direct care staff, licensee,
and members of the household; provision of names of
employee, volunteer, or member of the household on
parole or probation or convicted of felony; food service
staff.

(9) A licensee and the administrator shall possess all of


the following qualifications:
(a) Be suitable to meet the physical, emotional,
social, and intellectual needs of each resident.

ANALYSIS: The Home Manager, Ken Franklin, and staff member, Di’Angelo
Carlton, stated that the licensee designee/administrator,
Theressa Nelson, has not been to the facility in quite a while.
Mr. Franklin has also not been at the facility to oversee and
supervise the staff. According to Mr. Carlton, since there is no
supervision, staff has become relaxed without the presence of
Ms. Nelson to run things properly. The staff and the facility have
been neglected without anyone to supervise the residents and
keep the facility in order.

CONCLUSION: VIOLATION ESTABLISHED

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APPLICABLE RULE
R 400.14201 Qualifications of administrator, direct care staff, licensee,
and members of the household; provision of names of
employee, volunteer, or member of the household on
parole or probation or convicted of felony; food service
staff.

(10) All members of the household, employees, and


those volunteers who are under the direction of the
licensee shall be suitable to assure the welfare of
residents.

ANALYSIS: According to the Home Manager, Ken Franklin, and staff


member, Di’Angelo Carlton, the licensee designee/
administrator, Theressa Nelson, has not been to the facility in
quite a while. Ken Franklin and Di’Angelo Carlton stated that
the Licensee Designee, Theressa Nelson has been ill and has
not been to the facility in many months. Mr. Franklin has also
not been at the facility to oversee and supervise the staff,
although he is returning very soon and he is aware that order
needs to be restored to the facility to provide suitable care to
the residents. Since there is no supervision, according Mr.
Carlton, staff have become lax without the presence of Ms.
Nelson and Mr. Franklin. Staff are not washing resident’s
clothes in a timely manner, residents do not have sheets or
blankets on their beds, staff are swearing at the residents and
treating them disrespectfully, and staff are not maintaining the
clutter and order of the resident’s bedrooms.

CONCLUSION: VIOLATION ESTABLISHED

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IV. RECOMMENDATION

Based upon the rule violations found in this facility, a six-month provisional license is
recommended.

8/23/2019
Theresa Cipponeri Date
Licensing Consultant

Approved By:

08/23/2019
________________________________________
Denise Y. Nunn Date
Area Manager

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