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Theressa Nelson
My Beloved Group Home
24260 Radclift Street
Oak Park, MI 48237
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:
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.
Sincerely,
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
Capacity: 6
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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.
Residents do not have clean clothes and at times have had to Yes
wear the same clothes for several days in a row.
III. METHODOLOGY
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07/22/2019 Contact - Telephone call received
Received voicemail message from the RS, requesting a return
call.
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08/09/2019 Contact - Telephone call made
Interviewed the Home Manager, Ken Franklin, via telephone.
ALLEGATION:
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 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.
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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.
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 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.
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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.
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.
ALLEGATION:
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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 8/12/2019, 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.
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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.
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.
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.
ALLEGATION:
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.
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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.
APPLICABLE RULE
R 400.14403 Maintenance of premises.
APPLICABLE RULE
R 400.14403 Maintenance of premises.
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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.
APPLICABLE RULE
R 400.14411 Linens.
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.
APPLICABLE RULE
R 400.14411 Linens.
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.
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.
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.
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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.
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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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