SHALOM HOME CARE LLC

SUMMARY OF FINDINGS:On 1/21/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Client (A) alleged about a month ago they were raped twice. During the course of the investigation the healthcare entity ensured the client was safe. The police were notified, and ruled the the allegation was more likely due to the client's history of hallucinations. The accused client (B) denied the allegations and filed a defamation of character against Client (A). Staff informed both clients to avoid each other. Staff will monitor Client (B)’s behaviors closer and they will continue working with the psychiatrist on behavior management instead of using false accusations when upset. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 4/3/2026 · released to the public 4/10/2026.

SUMMARY OF FINDINGS:On 10/6/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. An at risk person was missing for six hours after the police found them during a missing persons search. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified, the client was found and taken to the hospital for mental health treatment and until they were stable as the client had marijuana in their system. When the client returned their care plan was updated with a behavior contract, and they were reminded to use the sign in and out log. The client was also educated to not associate themselves with the wrong people. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 1/26/2026 · released to the public 2/2/2026.

DESCRIPTION OF OCCURRENCE: On 1/12/23 a male resident (A) in his 40s went out on a community pass and was due to return later that day by midnight. Resident (A) did not return by that time nor did he call the facility. After a search of the premises was conducted resident (A)’s whereabouts were unknown. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. The facility called the hospitals, local crisis centers, resident (A)’s family, case manager, and checked the local park where resident (A) would normally hang out at. No one had heard or seen resident (A). The facility investigation concluded the resident (A) left on pass and did not return as indicated and had not communicated with the facility. At the time of the final report resident (A) was still missing. A follow up report indicated the police department called the facility on 2/13/23 to follow up and report resident (A) had been found but did not want to return to the facility. The facility asked the police to take resident (A) to a crisis center because he would need his medications and resident (A) refused that as well and the police could not force him to go. The police stated he did not appear to pose a risk to himself or others. The case was closed as a missing persons case with the police department and the facility and the resident did not want to return to living at the facility. The case manager and his psychiatrist were involved with resident (A) and hopefully he will take advice for treatment. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 7/10/2023 · released to the public 7/13/2023.