Marvella.
Marvella is Grade C, ranked in the top 43% of Minnesota memory care with 1 MDH citation on record; last inspected Nov 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Marvella has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Marvella's record and state requirements.
The facility holds an Assisted Living Facility with Dementia Care license under Minnesota Statutes chapter 144G — can you provide a copy of your current written dementia care program and explain how it addresses the specific needs of residents with memory impairment?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Minnesota Department of Health records show one complaint was filed during the inspection period — was that complaint substantiated, and can you share the facility's internal documentation of how it was resolved?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The most recent MDH inspection on November 20, 2025 resulted in zero deficiencies — can you walk us through the preparation process your team uses before state surveys and how you maintain compliance between inspections?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-11-20Annual Compliance VisitNo findings
Plain-language summary
During a routine inspection on November 20, 2025, Minnesota Department of Health found that the facility was not in compliance with state infection control program requirements under Minnesota Statute 144G.41, Subdivision 3. The facility received a Level 2 correction order and was assessed a $500 fine for this violation. The facility must document the actions it has taken to correct the infection control deficiency within the timeframe specified on the state form.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO NORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." 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; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Marvella December 19, 2025 Page 2 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 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 $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject 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 within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee( s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with · the specific statute( s). 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. Marvella December 19, 2025 Page 3 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 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. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/ or investigation process. Please fill out this anonymous provider feedback questionnaire at your conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan. winkelmann@state. mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Renee L. Anderson, Supervisor State Evaluation Team Email: Renee. L.Anderson@state. mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 CLN PRINTED: 12/ 19/ 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: ______________________ B. WING _____________________________ 39444 11/20/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 822 WOODLAWN AVENUE MARVELLA SAINT PAUL, MN 55116 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G. 08 to 144G. 95, these correction orders are left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL39444016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 17, 2025, through November 20, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 169 residents; 50 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. 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. 0 130 144G. 12, Subd. 1 Application for Licensure 0 130 SS= C Each application for an assisted living facility LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ZLQ211 If continuation sheet 1 of 14 PRINTED: 12/ 19/ 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: ______________________ B.
2025-02-28Complaint Investigation1 · Substantiated Finding
Plain-language summary
A Minnesota Department of Health investigation of a maltreatment complaint substantiated that a facility staff member financially exploited residents through unauthorized credit card charges and theft of cash and jewelry; evidence included approximately $4,810 in charges made to the staff member's apartment rent and personal purchases at retailers, with similar patterns of fraud identified on a second resident's card. The staff member denied the allegations, but law enforcement determined there was sufficient evidence to pursue felony credit card fraud charges. Cash and a wedding ring belonging to one resident could not be definitively attributed to the staff member due to uncertain timing and multiple people having access to resident areas.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, individual responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator (AP), a facility staff member financially exploited resident #1 and resident #2. The AP used resident #1’s credit card and made unapproved charges and took resident #1’s wedding ring. Resident #2 was financially exploited when the AP took $40.00 from the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. During the course of the investigation, it was discovered resident #1 and resident #4 had charges made on their credit card that totaled almost $5,000.00 from vendors used by the AP including apartment rent. Although resident #1 lost a wedding ring and cash, and resident #2, resident #3, resident #4 had cash taken from them, it could not be determined if the AP took the wedding ring and cash because of the uncertain time frame of the incidents, no witnesses, and the number of people that had access to the resident’s apartments. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and a business owner where charges were made on resident #1’s credit card. The investigation included review of the resident records, facility internal investigation, personnel files, tenant log sheet, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator made observations of staff and resident interactions during an onsite visit. Resident #1 resided in an assisted living facility. Resident #1’s diagnoses included a stroke. The resident’s service plan included assistance with morning and evening cares. The resident’s assessment indicated the resident had intact cognition and was independent with financial decisions. Resident #4 resided in an assisted living facility. Resident #4’s diagnoses included dementia. The resident’s service plan included assistance with homemaking services. The resident’s assessment indicated the resident had intact cognition and was independent with financial decisions. Facility documents indicated one day, resident #1’s family member notified facility leadership that resident #1’s money clip containing cash, wedding ring, and a credit card were missing. At that time, Resident #1’s credit card statement indicated 51 charges totaling $4,810.00 were made. The facility document indicated the police were notified. The AP’s payment ledger from the AP’s apartment complex indicated the AP made an online payment with a credit card for $750.00. Seven days later, the AP made another online payment with a credit card for $500.00. Four days later, the AP made another online payment with a credit card for $150.00 The AP’s payment ledger indicated all three payments were disputed (a consumer requested their credit card company remove an incorrect or fraudulent charge from their bill). Resident #1’s credit card statement indicated charges were made to an apartment complex with the same address as the AP. The same days as the tenant log sheet, resident 1’s credit card indicated charges of $772.13, $514.75 and $154.43. In addition, resident 1’s credit card had charges made to a nail salon, transportation companies, luxury wig store, hair salon, food delivery services, prepaid phone, handbag store, and a women’s clothing website. Correspondences between law enforcement and the apartment complex indicated the difference in amounts on the credit card statement and the amount on the AP’s payment ledger is because additional processing charges were applied. Resident #4’s credit card statement had highlighted areas that indicated approximately $130.00 was spent on food and transportation similar to the charges made by the AP for resident #1. During an interview, the human resource director stated they determined it was the AP, because resident #1’s bank statement had a repeated charge to an apartment complex, the same apartment complex that the AP lived at. Human resources stated they called the apartment complex and spoke to a representative that confirmed the AP used a credit card to pay her rent. The AP also used resident #1’s credit card at a luxury wig store, nail salon, and transportation companies. During an interview, the resident service director stated during the investigation of resident #1’s missing cash and credit card, it was discovered that resident #4 had received a letter from his bank that indicated suspicious charges were made on his credit card. Resident #4’s credit card had similar charges as resident #1’s charges on his credit card. During an interview, the owner of the luxury wig store stated the AP was a client of the store and used a credit card to pay for the items that came back as disputed. The owner stated she did not remember the actual name on the credit card, but the name was not the AP’s name. During an interview, the AP denied stealing credit cards from residents. Correspondence with law enforcement indicated charges for felony transaction credit card fraud would be made against the AP. During an interview, resident #1’s family member stated the resident does not leave the assisted living without assistance. The family member stated the charges on resident #1’s credit card was not items resident #1 would have purchased. In conclusion, the Minnesota Department of Health determined financial exploitation was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority, a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Yes, all four residents were interviewed. Family/Responsible Party interviewed: Resident #1 and resident #2’s family member was interviewed. Resident #3 and resident #4 were their own person. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility completed an internal investigation, notified the police and suspended the AP. The AP is no longer employed by the facility. Action taken by the Minnesota Department of Health: The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html You may also call 651-201-4200 to receive a copy via mail or email. The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Ramsey County Attorney St. Paul City Attorney St. Paul Police Department PRINTED: 02/28/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 39444 01/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 822 WOODLAWN AVENUE MARVELLA SAINT PAUL, MN 55116 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 CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag.
2023-11-10Annual Compliance VisitNo findings
Plain-language summary
A standard inspection of this assisted living facility with dementia care was completed on November 10, 2023, and state correction orders were issued for violations of Minnesota statutes, though no immediate fines were assessed. The facility must document the actions it took to correct the identified areas of noncompliance within the timeframe specified on the state form. The facility has the right to request reconsideration of the correction orders within 15 calendar days of receipt.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. Additionally, please note this license is granted while MDH interpretation of Minnesota Statutes Chapter 144G is under review. This grant of license does not constitute a determination related to the issues under review, and additional action by the licensee may be required based on the outcome of this review. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), t he licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Marvella April 11, 2024 Page 2 Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s residents/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order 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 the Department of Health within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. 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. If you have any questions, please contact me. Sincerely, Renee Anderson, Supervisor State Evaluation Team Email: renee.anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 HHH PRINTED: 04/11/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39444 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 822 WOODLAWN AVENUE MARVELLA SAINT PAUL, MN 55116 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 Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL39444015-0 PLEASE DISREGARD THE HEADING OF On November 6, 2023, through November 9, THE FOURTH COLUMN WHICH 2023, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted an initial survey at the above provider, CORRECTION." THIS APPLIES TO and the following correction orders are issued. At FEDERAL DEFICIENCIES ONLY. THIS the time of the survey, there were 39 residents, WILL APPEAR ON EACH PAGE. who received services under the provider's Assisted Living with Dementia Care Facility THERE IS NO REQUIREMENT TO provisional license. 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 pursuant to 144G.31 Subd. 1, 2 and 3. 0 130 144G.12, Subd. 1 Application for Licensure 0 130 SS=C Each application for an assisted living facility license, including provisional and renewal applications, must include information sufficient to show that the applicant meets the requirements LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 R2MF11 If continuation sheet 1 of 16 PRINTED: 04/11/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39444 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 822 WOODLAWN AVENUE MARVELLA SAINT PAUL, MN 55116 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) 0 130 Continued From page 1 0 130 of licensure, including: (1) the business name and legal entity name of the licensee, and the street address and mailing address of the facility; (2) the names, e-mail addresses, telephone numbers, and mailing addresses of all owners, controlling individuals, managerial officials, and the assisted living director; (3) the name and e-mail address of the managing agent and manager, if applicable; (4) the licensed resident capacity and the license category; (5) the license fee in the amount specified in section 144.122; (6) documentation of compliance with the background study requirements in section 144G.13 for the owner, controlling individuals, and managerial officials. Each application for a new license must include documentation for the applicant and for each individual with five percent or more direct or indirect ownership in the applicant; (7) evidence of workers' compensation coverage as required by sections 176.181 and 176.
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