Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00451172-AP-403371
Provider Information
Stephanie Gardens Residential Care
19751 SE STARK ST
Portland, OR 97233
- Provider ID
- 50R503
- Administrator
- Jason Wart
- Phone
- (971) 292-2265
- ed@stephanieresidential.com
Violation Details
- Date
- 1/15/2026
- Report number
- 00451172-AP-403371
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(l)
External site: 411-054-0036(2)(g)
- Findings
- On January 20, 2026, ODHS Adult Protective Services (APS) completed investigation #00451172 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility and had a documented history of leaving prior care settings, placing AV’s safety at significant risk. AV’s service plan identified AV as being at risk for elopement; however, the facility failed to implement adequate interventions to mitigate this risk. Based on facility documentation and staff interviews, AV eloped on two separate occasions: On or about January 14, 2026: AV exited the facility unnoticed before the automatic door lock re-engaged. After leaving the secure area, AV entered the exterior courtyard and was able to leave the courtyard due to the gate either being left unsecured or in disrepair. AV then exited the courtyard and was observed by staff running across a major street, creating a significant safety hazard. AV did not sustain physical injuries but was tearful and verbalized distress upon returning to the facility. Following this incident, staff were instructed to ensure all doors were locked prior to leaving them unattended. There was no policy in place prior to this event requiring staff to do so. On or about January 16, 2026, AV was standing near the memory care front door when a visitor entered. AV quickly pushed past the visitor and the secure door, then ran to a second set of automatically locking doors and was able to pull them open. AV exited the facility through the front door unnoticed by staff. During both elopements, AV was observed walking and/or running along a heavily traveled four-lane street. Both incidents demonstrate that the facility failed to implement effective interventions to address AV’s identified elopement risk, resulting in potential for serious harm. The facility's failure to properly care plan for AV's known elopement risk is a violation of resident rights, is considered neglect of care, which constitutes abuse.
- Sanction
- RCFCP26-00079 $1125.00 fine assessed