- Date
- 4/22/2026
- Report number
- 00472151-AP-424535
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about April 22, 2026, Alleged Victim (AV) exited the secured building, placing AV at risk of harm. Facility documentation and interviews confirmed that Alleged Perpetrator 2 (AP2) was recorded on facility video footage assisting AV through a locked door. AP2 stated at time of incident, AP2 believed AV was a visitor not a resident. Law enforcement later located AV at a bus stop approximately five miles from the facility. AV refused to return and was transported to the hospital on a hold for evaluation. AV returned to the facility later the same day. The APS investigator determined AP2 did not follow established facility procedures as outlined in AP2's completed trainings. AP2 had completed online elopement-prevention training and received instruction on proper entry and exit from the secured area. AP2 also acknowledged understanding that residents must not be allowed to leave the secure area without verifying their identity and assessing their risk of elopement. By enabling AV to exit the secure facility, AP2 placed AV at risk of harm. AP2’s actions constitutes neglect, which constitutes abuse. Additionally, the facility failed to maintain a safe environment for AV, resulting in a violation of Oregon Administrative Rules.