ODHS Licensing or Staffing Complaint

Adaptive Form Header
Purpose
Your information
Resident information
Facility information
Details of complaint or incident
Next steps
Adaptive Form Footer

Purpose
Your information
Resident information
Facility information
Details of complaint or incident
Next steps

Oregon Department of Human Services (ODHS)

Licensing or Staffing Complaint

Purpose

Use this form to submit a complaint for Community-Based Care (CBC) facilities. Examples of CBCs include assisted living facilities and residential care facilities including endorsed memory care. You can report:

A licensing violation, other than abuse, that alleges harm or that there may be harm to a resident, or
Too few qualified direct care staff to meet each resident's needs 24 hours a day.

If your complaint is not a CBC licensing violation or CBC staffing concern:

Report concerns about a Nursing Facility at 877-280-4555 or nf.complaints@odhsoha.oregon.gov.
Report potential abuse by contacting your local Oregon Department of Human Services (ODHS) office or calling 855-503-SAFE (7233).
Report concerns about an Adult Foster Home by contacting your local Oregon Department of Human Services (ODHS) office or calling 855-503-SAFE (7233).

All reports are confidential. Complete the form as best you can. Give as much detail as you are able to share. The information you fill in below is needed for screening of the concern. Complete information is essential to complete the screening process.

Starred (*) fields are required.

Your information

Your first name:

Your last name:

Your title, if relevant to the complaint:

Your relationship with the resident:

Your phone number:

Your email address is required. That is how you will get a summary of your submitted report. Adding your address and phone number is not required, but will make it easier for the department to follow up with you.

Your email address: *

Please re-enter your email address to confirm it: *

Note: If you want us to mail you a copy of the final investigation, please give us your complete mailing address, including your city, state and ZIP code.

Mailing address:

City:

State:

ZIP code:

Resident information

Resident's name: *

Resident's date of birth, if known (MM/DD/YYYY):

Do they get Medicaid services? *

Facility information

Facility name: *

Facility type:

Facility location or full address: *

Details of complaint or incident

Date of incident (MM/DD/YYYY): *

Time or shift of incident:

Name of staff, if involved:

Staff member title, if involved:

How did you become aware of this complaint? *

If "Other," describe how you got the complaint: *

Is your complaint about harm concerns? *

Is your complaint about staffing levels? *

Describe the complaint or incident

For harm complaints: Include how the harm occurred or could occur.
For staffing complaints: Include if any needs of residents were missed.

Describe your complaint. Be specific. *

Next steps

After you click Submit:

Your complaint will go to the Oregon Department of Human Services (ODHS).
You will get an email confirmation with the details of your complaint.
Someone will reach out to you within ten (10) business days to follow up with questions and next steps.

Email questions to Licensing.Complaint@odhsoha.oregon.gov.

You can get this document in other languages, large print, braille or a format you prefer. Contact ODHS toll-free at 1-844-503-4773 or email Licensing.Complaint@odhsoha.oregon.gov. We accept all relay calls or you can dial 711.