Guardian Angel Homes

Last inspection

November 24, 2025

Inspections

6, 6 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$250.00 (1 violation)

Current owner since

June 3, 2013

Inspections

• November 24, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• July 17, 2025: Complaint Investig., 1 deficiency cited report
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• November 4, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• August 7, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• April 3, 2023: Validation, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected June 5, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected June 5, 2023
• July 6, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 6, 2022

Substantiated abuse or neglect

• April 18, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) and Witness 1 (W1) are residents in AP1. On or about April 18, 2025, W1 attacked AV from behind, pushing AV to the floor. While AV was on the ground, W1 repeatedly struck and stabbed AV using a fly swatter and a plastic knife. AV sustained multiple injuries, including scratches, bumps, and discoloration. There is a documented history of W1 targeting AV prior to this incident. W1 had an existing behavior plan specifically addressing this issue. As of February 4, 2025, W1’s service plan directed staff to keep AV and W1 separated. AV did not provoke the incident. The facility failed to follow W1’s service plan and did not take appropriate measures to ensure AV’s safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• August 20, 2024: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care and is care planned to have a bed alarm in place due to being a fall risk. According to an investigation, on or about August 20, 2024, the Alleged Perpetrator 2 (AP2), provided assistance to AV, and then helped AV back into bed. Approximately 30 minutes later AV was found on the floor after a fall. AV's bed alarm was not going off and it was discovered that AP2 did not turn AV's bed alarm back on after providing initial care, and therefore staff were not alerted that AV had gotten up, resulting in a fall with a fracture. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

• April 22, 2024: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to implement an approved proprietary Acuity-Based Staffing Tool (ABST). The proprietary currently in use has not been submitted for review and approval by the Department. An investigation determined this is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 40 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.