The state has taken the unprecedented step of revoking the license of a foster care placement agency following the death of a 6-year-old girl in one of its foster homes late last year.

Announced Friday, the Department of Human Services (DHS) action against Family Alternatives, a Minneapolis nonprofit, could affect foster children in all 69 homes that the agency oversees. Family Alternatives supervised the Brooklyn Park foster home where 6-year-old Kendrea Johnson was found hanging from a jump rope tied to her bunkbed.

The department also revoked the license of Kendrea’s foster mother, Tannise Nawaqavou, saying it found “serious and chronic” licensing violations at the home. DHS had suspended her license after Kendrea’s death.

A DHS investigation determined that Family Alternatives repeatedly failed to investigate complaints about Kendrea’s foster mother since 2012, including several reports while the girl lived with her. Those reports included an incident where the girl was locked in her room, and another when she was found with her pants down with another foster child.

The department blamed Nawaqavou for failing to arrange background studies for household members; neglecting to report an incident regarding possible sexual contact of a foster child; failing to provide “consistent adult supervision” in the home, and providing false and misleading information, according to DHS.

However, the DHS investigation determined that there was not “a preponderance of the evidence that there was a failure to provide [Kendrea] with necessary supervision” the night she died, so it could not substantiate any maltreatment.

Nawaqavou and Family Alternatives did not respond to requests for comment.

‘Just didn’t get shared’

In January, the Star Tribune reported how child protection workers and care providers failed to work together for more than a year to safeguard Kendrea, despite knowing she was severely mentally ill, thought about suicide every day and lived in a chaotic foster home.

Kendrea was placed in foster care in December 2013. Records show her behavior then changed dramatically. Nawaqavou told Brooklyn Park police that the girl once threatened to kill her with a screwdriver. Kendrea also told her foster mother that she wanted to jump out a window and kill herself, said “Nobody likes me” and drew pictures at school of a child hanging from a rope.

Her foster father told police that on Dec. 27, he checked on Kendrea about 8 p.m. and that she appeared to be standing on her bed and watching television, a police report said. He checked on her 10 minutes later and she was still in the same position, but this time hanging in a noose made from a jump rope.

A white three-gallon bucket was nearby. On the floor, a note written by a child in purple marker on a page torn from a book started with, “I’m sorry.” Another note said, “I’m sad for what I do.”

Although the Hennepin County medical examiner couldn’t determine the manner of Kendrea’s death, investigators strongly considered the possibility of suicide.

Brooklyn Park Deputy Police Chief Mark Bruley had said that the evidence kept leading investigators to the belief that she intentionally killed herself, but that the department also agreed with the medical examiner that such an act is “outside what a normal 6-year-old could think about.”

DHS Inspector General Jerry Kerber said the DHS investigation found that Kendrea’s death was likely an accident, and could not link it directly to failed oversight by Family Alternatives. Still, the DHS reports concluded that Kendrea’s care providers were not communicating with one another about the girl’s needs.

The girl’s day treatment facility, Shoreview-based LifeSpan, did not tell Nawaqavou that the girl was suicidal, DHS said.

“They were silos of people that knew information about this child, and that just didn’t get shared,” Kerber said Friday. Family Alternatives “had a responsibility from our perspective to really coordinate that communication.”

Family Alternatives oversees 69 homes in nine Minnesota counties, with more than half in Hennepin, records show. DHS records show that Family Alternatives has been cited for 38 licensing violations since 2011, including a lack of required documentation in the files of homes or children, missing background checks and failure to take action against homes found in violation of foster care rules.

Kerber said DHS was already investigating Family Alternatives when the girl died. The department found that Family Alternatives failed to investigate numerous reports at other foster homes it oversees, including a report that a foster child was sexually assaulted.

Family Alternatives was “not taking their role seriously enough as having the oversight responsibilities for the foster care providers that were under them,” Kerber said.

Family Alternatives can operate until at least April 10. If the agency appeals, it can operate for another 90 days. Having reviewed the organization’s records, Kerber said, DHS will investigate other homes overseen by Family Alternatives, and move children if violations are found. But DHS and Hennepin County said they want to keep children in their current foster homes if possible.

“We are following up immediately to determine how many Hennepin County youths we have in all Family Alternative foster homes and to conduct contingency planning, as appropriate,” Assistant Hennepin County Administrator Rex Holzemer said Friday. “We will be making every effort to avoid moving children if it is not necessary.”