Federal inspection record · CMS data as of October 1, 2026
Grand Oaks Care
897 North M Street, Tulare, CA · (559) 687-1340
- Certified beds
- 99
- Residents per day
- 94
- Ownership
- For-Profit
- Chain
- Ajc Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 26, 2009
1
How this home got 3 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.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Grand Oaks Care carries 79 inspection points. That is fewer than 55% 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
55 health citations on record since 2022. 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.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care11E
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- E
Provide activities to meet all resident's needs.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Resident Assessment and Care Planning10E
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- 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
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
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.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Rights10E
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Pharmacy Service7E
- 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
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary7F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Nursing and Physician Services2F
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Administration2F
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- E
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Environmental2E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspection history
2026-02-12
7 health deficiencies · 5 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2024-10-10
22 health deficiencies · 8 fire-safety deficiencies
Top issue: Resident Rights (7 deficiencies)
2022-10-13
26 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 22 min of nursing staff time a day, 22 min of it from a registered nurse.
This home
4 h 22 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 46% 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
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 better | 1.9 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts worse | 1.9 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 100.0% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.4 pts better | 1.2% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.6 pts better | 3.0% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.6 pts worse | 5.7% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.8 pts worse | 21.5% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication8.4 pts better | 3.9% | 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 worsened10.2 pts worse | 19.1% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased5.6 pts better | 4.6% | 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 infection1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.6 pts worse | 14.4% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.9 pts better | 0.4% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.4 pts better | 100.0% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit8.1 pts worse | 19.2% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.4 pts better | 0.9% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.9 pts better | 100.0% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission12.2 pts worse | 34.8% | 22.6% | 23.4% |
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Who owns and runs it
4 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 |
|---|---|---|---|
| Swc Ca Opco 2 LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 10 facilities |
| Chesley, Aaron | Corporate Officer · Individual | 0% | 21 facilities |
| Gamett, James | Corporate Officer · Individual | 0% | 20 facilities |
| Lawrence, Michelle | W-2 Managing Employee · Individual | 0% | 2 facilities |
·
Fire safety
17 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke5D
- D
Provide properly protected cooking facilities.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Properly provide smoke detection systems in areas open to corridors.
- D
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous4F
- F
Provide a written emergency evacuation plan.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- E
Have simulated fire drills held at unexpected times.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems3E
- E
Ensure proper usage of power strips and extension cords.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have proper medical gas storage and administration areas.
Emergency Preparedness2C
- C
Provide primary/alternate means for communication.
- C
Conduct testing and exercise requirements.
Egress1D
- D
Have properly located and lighted "Exit" signs.
Construction1D
- D
Use approved construction type or materials.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
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Other homes nearby
-
Orchards At Tulare
Tulare, CA · Ajc Healthcare
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 5 h 23 min
- Fines
- $68,938
-
Tulare Healthcare & Wellness Center, LP
Tulare, CA · Corporate Interface Services
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 7 min
- Fines
- $0
-
Westgate Gardens Care Center
Visalia, CA · Pacs Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 4 min
- Fines
- $10,317