Nursing homeActive
College Oak Nursing and Rehabilitation Center
4635 College Oak Drive, Sacramento, CA 958419164817434120 certified beds · 115 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
8
since 2023
Deficiencies
25
● 0● 23● 2
Penalties · 3 yrs
$9,814
1 fine
Last survey
2026-05-29
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 3
Staffing 4
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-04-09 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2025-11-20 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-02-07 | Standard | 0100 | CMS-2567 (Care Compare) | — |
| 2024-10-24 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-06 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-02-09 | Standard | 031 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-10Record 056158-20260529-F628
F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 056158-20260409-F559
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 056158-20260409-F697
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 056158-20260409-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 056158-20260409-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 056158-20260409-F842
F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-11-25Record 056158-20251120-F627
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-25Record 056158-20251120-F628
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F558
F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F640
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F658
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F759
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F812
F814Dispose of garbage and refuse properly.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F814
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-28Record 056158-20250207-F880
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-04Record 056158-20241024-F806
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 056158-20240806-F658
F685Assist a resident in gaining access to vision and hearing services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-02-23Record 056158-20240209-F685
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-23Record 056158-20240209-F679
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-23Record 056158-20240209-F759
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-23Record 056158-20240209-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-20Record 056158-20231005-F684
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-11-20 | Civil money penalty | $9,814 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.81
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day4.33
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours3.92
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover40%
Facility
California
National
California 37% · National 46%
Registered nurse turnover47%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 3.4% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.6% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 5.5% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.0% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 10.9% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 5.6% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 9.4% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Borja, Jean Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Green-Rastekhiz, Emilee Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hadrick, Stephany Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Jackson, Matthew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Jackson, Robert Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Khan, Alzeena Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mcconnell, Christopher Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Roldan, Mary Rose Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sandhu, Harkesh Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sanofsky, Jack Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Singh, Shalini Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Watkins, Michael Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Borja, Jean Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Green-Rastekhiz, Emilee Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Hadrick, Stephany Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Jackson, Matthew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Jackson, Robert Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Khan, Alzeena Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mcconnell, Christopher Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Roldan, Mary Rose Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Sandhu, Harkesh Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Sanofsky, Jack Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Singh, Shalini Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Watkins, Michael Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Cypress Healthcare Group — 13 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for Sacramento.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Eskaton Village Care Center Carmichael | 0.9 mi | 2026-04-14 | 0380 |
| Sacramento Post-Acute Sacramento | 1.1 mi | 2026-02-20 | 0230 |
| American River Center Carmichael | 1.1 mi | 2026-04-10 | 0240 |
| Whitney Oaks Care Center Carmichael | 1.4 mi | 2026-05-28 | 0531 |
| Mission Carmichael Healthcare Center Carmichael | 1.4 mi | 2026-05-22 | 0500 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |