Federal inspection record · CMS data as of October 1, 2026
College Oak Nursing and Rehabilitation Center
4635 College Oak Drive, Sacramento, CA · (916) 481-7434
- Certified beds
- 120
- Residents per day
- 113
- Ownership
- For-Profit
- Chain
- Cypress Healthcare Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 16, 1970
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
College Oak Nursing and Rehabilitation Center carries 89.5 inspection points. That is fewer than 48% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
26 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
-
G
Assist a resident in gaining access to vision and hearing services.
Everything else, by area of care
Resident Rights5D
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Reasonably accommodate the needs and preferences of each resident.
Pharmacy Service5E
- D
Ensure 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.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- E
Ensure 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.
- D
Ensure medication error rates are not 5 percent or greater.
Resident Assessment and Care Planning5D
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Nutrition and Dietary4F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Dispose of garbage and refuse properly.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Quality of Life and Care3D
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Infection Control2E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Inspection history
2026-04-09
9 health deficiencies · 6 fire-safety deficiencies
Top issue: Resident Rights (5 deficiencies)
2025-02-07
11 health deficiencies · 5 fire-safety deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2024-02-09
6 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 17 min of nursing staff time a day, 47 min of it from a registered nurse.
This home
4 h 17 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 38% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$9,814 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-11-20 | Fine | $9,814 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts worse | 2.5 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident daysAbout the same | 1.5 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1 pts better | 99.7% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine8.1 pts worse | 89.8% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injuryAbout the same | 1.6% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6.2 pts better | 1.4% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.4 pts worse | 6.5% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.2 pts better | 8.5% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication7.4 pts better | 4.9% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened8.9 pts worse | 17.8% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.3 pts worse | 12.5% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 0.0% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.2 pts better | 1.0% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.5 pts worse | 11.3% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.2 pts better | 4.1% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine2.6 pts worse | 92.0% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.5 pts worse | 12.6% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.1 pts better | 0.2% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine1.4 pts worse | 91.7% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.3 pts better | 19.3% | 22.6% | 23.4% |
·
Who owns and runs it
24 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Borja, Jean | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Borja, Jean | Adp Of The SNF · Individual | 0% | 1 facilities |
| Green-Rastekhiz, Emilee | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Green-Rastekhiz, Emilee | Adp Of The SNF · Individual | 0% | 1 facilities |
| Hadrick, Stephany | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Hadrick, Stephany | Adp Of The SNF · Individual | 0% | 1 facilities |
| Jackson, Matthew | Corporate Officer · Individual | 0% | 13 facilities |
| Jackson, Matthew | Operational/Managerial Control · Individual | 0% | 13 facilities |
| Jackson, Robert | Corporate Officer · Individual | 0% | 15 facilities |
| Jackson, Robert | Operational/Managerial Control · Individual | 0% | 15 facilities |
| Khan, Alzeena | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Khan, Alzeena | Adp Of The SNF · Individual | 0% | 1 facilities |
| Mcconnell, Christopher | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Mcconnell, Christopher | Adp Of The SNF · Individual | 0% | 1 facilities |
| Roldan, Mary Rose | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Roldan, Mary Rose | Adp Of The SNF · Individual | 0% | 1 facilities |
| Sandhu, Harkesh | Operational/Managerial Control · Individual | 0% | 6 facilities |
| Sandhu, Harkesh | Adp Of The SNF · Individual | 0% | 6 facilities |
| Sanofsky, Jack | Corporate Officer · Individual | 0% | 27 facilities |
| Sanofsky, Jack | Operational/Managerial Control · Individual | 0% | 27 facilities |
| Singh, Shalini | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Singh, Shalini | Adp Of The SNF · Individual | 0% | 1 facilities |
| Watkins, Michael | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Watkins, Michael | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
14 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke9E
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install corridor and hallway doors that block smoke.
- C
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install corridor and hallway doors that block smoke.
- D
Inspect, test, and maintain automatic sprinkler systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Gas, Vacuum, and Electrical Systems3F
- D
Ensure proper usage of power strips and extension cords.
- D
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Construction1D
- D
Use approved construction type or materials.
Miscellaneous1D
- D
Provide a written emergency evacuation plan.
·
Other homes nearby
-
Eskaton Village Care Center
Carmichael, CA
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 6 h 3 min
- Fines
- $0
-
Sacramento Post-Acute
Sacramento, CA · Pacs Group
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 36 min
- Fines
- $0
-
American River Center
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★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 53 min
- Fines
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