Sunset Estates

Last inspection

June 24, 2024

Inspections

4, 9 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

12

Regulatory actions

1

Fines assessed

$500.00 (2 violations)

Current owner since

July 30, 2014

• No deficiencies cited at the last inspection (June 2024)
• Every deficiency from the December 18, 2023 inspection was corrected by February 17, 2024

License conditions and other regulatory actions

• September 18, 2025 to October 8, 2025: License Condition, Failed to provide safe environment RCFCD25-01046; incident: CALMS - 00087906
  On September 17, 2025, the Department opened an LCU investigation and based on preliminary information ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration)

Inspections

• June 24, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• December 18, 2023: Validation, 9 deficiencies cited report
  • C0000: Comment severity level 0
  • C0242: Resident Services: Activities severity level 2, scope L2 Pattern, corrected February 17, 2024
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected February 17, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected February 17, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected February 17, 2024
  Show all 10

  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected February 17, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected February 17, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected February 17, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 17, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected February 17, 2024
• July 31, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• November 1, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• September 19, 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)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. AV is impulsive and is at risk for elopement. According to an investigation, on or about September 19, 2025, the facility door's magnetic locking mechanism failed, resulting in AV leaving the facility. AV was gone for approximately ten minutes, placing AV at risk of harm. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care which constitutes abuse.

• February 14, 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

  The Alleged Victim (AV) relies on the facility for his/her care. AV and Witness 6 (W6) have a history of resident-to-resident altercations and W6 has a recent history of repeated sexual behaviors. According to an investigation, on or about February 14, 2025, W6 was observed leaving AV's room when AV was found with pants pulled down. W6 reported pulling down AV's pants, resulting in a violation of AV's privacy and rights. At the time of the incident, W6's service plan identified a high risk of sexual behaviors towards other residents but did not provide specific interventions for staff to follow when behaviors occurred. The facility failed to properly address resident behaviors, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• April 8, 2026: 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. AV was care planned to have a bed and chair alarm placed underneath them to keep them safe. Staff were to ensure that alarms are working properly at the end/beginning of all shifts. According to an investigation, on or about April 8, 2026, AV experienced a fall and was found on the floor, resulting in abrasions and discoloration. Alleged Perpetrator 2 (AP2) did not follow the care plan when they did not ensure the pressure alarm was correctly placed under AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The facility allegedly failed to follow the care plan for the Alleged Victim, which is a violation of Oregon Administrative Rules.

• February 8, 2026: 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. AV has a history of falls and is care planned to have a chair alarm placed under AV at all times and for staff to ensure alarms are working properly at the end/beginning of all shifts. According to an investigation, on or about February 8, 2026, AV fell injuring their right hand/wrist and causing pain. AV’s safety alarm failed to alert staff when AV stood up from their recliner. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) did not follow the care plan when they did not check AV’s alarm at the beginning of their shifts. AP2 and AP3’s actions are violations of resident rights and are considered neglect of care. The facility failed to ensure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.

• September 17, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0045 (Resident Health Services)
  State’s findings

  ?The facility failed to provide health services and have systems in place to respond to the 24-hour care needs of the residents with a system that had a licensed nurse delivering delegation and teaching. The facility’s failure is a violation of Oregon Administrative Rules.

• September 17, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0060 (Restraints and Supportive Devices)
  State’s findings

  The facility failed to ensure restraints were not used except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. The facility’s failure is a violation of Oregon Administrative Rules.

• September 17, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to have a safe medication and treatment administration system and provide adequate professional oversight of the medication and treatment administration system. The facility’s failure 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 16 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.