Happy Home Llc.

correction orders issued pursuant to the August 6, 2025 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on August 6, 2025, found not corrected at the time of the October 20, 2025, follow-up survey and/ or subject to penalty assessment are as follows: 0680-Disaster Planning And Emergency Preparedness- 144g.42 Subd. 10 - $500.00 0775-Fire Protection And Physical Environment- 144g.45 Subd. 2. (a) - $3,000.00 0780-Fire Protection And Physical Environment- 144g.45 Subd. 2 (a) (1) - $1,000.00 0950-Designation Of Representative- 144g.50 Subd. 3 1540-Training In Dementia, Mental Illness, And De--144g.64 (a) (3) - $500.00 2060-Assisted Living Facilities With Dementia Care-144g.81 Subd. 3 - $1,000.00 The details of the violations noted at the time of this follow-up survey completed on October 20, 2025 (listed above) , are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Also, at the time of this follow-up survey completed on October 20, 2025, we identified the following violation(s): 0340-Correction Orders- 144g.30 Subd. 5 - $3,000.00 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $9,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Happy Home LLC December 30, 2025 Page 2 to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you Happy Home LLC December 30, 2025 Page 3 may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. INFORMA LCONFERENCE In accordance with Minn. Stat. § 144A.475, Subd. 8 OR Minn. Stat. § 144G.20, Subd. 20, the Commissioner of Health is authorized to hold a conference to exchange information, clarify issues, or resolve issues. The Department of Health staff would like to schedule a conference call with Happy Hom e LLC. Please contact Stephanie Jones de Palma, at 651-201-4320 on or before Monday January 5, 2026, to schedule the conference call. We urge you to review these orders carefully. If you have questions, please contact Stephanie Jones de Palma at 651-201-4320. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Stephanie Jones de Palma, Supervisor State Engineering Services Section Email: stephanie. jones. de. palma@state. mn.us Telephone: 651-201-4320 Fax: 1-866-890-9290 HHH PRINTED: 12/ 30/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25323 10/ 20/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6660 WEST 175TH AVENUE HAPPY HOME LLC EDEN PRAIRIE, MN 55346 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 000} Initial Comments {0 000} ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE- ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL25323016- 1 far-left column entitled "ID Prefix Tag. " The state Statute number and the On October 20, 2025, the Minnesota Department corresponding text of the state Statute out of Health conducted a follow-up survey at the of compliance is listed in the "Summary above provider to follow-up on orders issued Statement of Deficiencies" column. This pursuant to a survey completed on August 6, column also includes the findings which 2025. At the time of the survey, there were five are in violation of the state requirement residents; five receiving services under the after the statement, "This Minnesota Assisted Living with Dementia Care license. As a requirement is not met as evidenced by." result of the follow-up survey, the following orders Following the evaluators' findings is the were issued and/ or reissued. Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 340 144G. 30 Subd. 5 Correction orders 0 340 SS= L (a) A correction order may be issued whenever LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 R3RL12 If continuation sheet 1 of 27 PRINTED: 12/ 30/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.