College Oak Nursing and Rehabilitation Center
4635 College Oak Drive, Sacramento, CA 95841 · Sacramento County · 120 certified beds · avg 115 residents/day · certified since Feb 16, 1970
Part of chain: CYPRESS HEALTHCARE GROUP (13 facilities, chain avg rating 3.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 20, 2025 · F-0627 · triggered by a complaint
The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 25, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2024 · F-0685
The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Why it matters: Untreated vision and hearing problems lead to falls, isolation, and confusion that could be avoided.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 23, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 29, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Apr 9, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Nov 20, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Oct 24, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 9, 2024 | ▲ G · Actual harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 6 | 1 | G ▲ |
| 2025 | 12 | 1 | J ▲ |
| 2026 | 6 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,814.
| Date | Type | Amount / length |
|---|---|---|
| Nov 20, 2025 | Fine | $9,814 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.27 | 4.31 | 3.95 | top 40% in California; top 30% in the U.S. |
| Registered Nurse hours | 0.79 | 0.61 | 0.69 | top 17% in California; top 28% in the U.S. |
| Weekend total nurse staffing | 3.87 | 3.90 | 3.50 | top 41% in California; top 27% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.58 | 0.51 | 0.48 | top 24% in California; top 25% in the U.S. |
| Total nursing staff turnover (%) | 40.0 | 36.7 | 45.8 | bottom 38% in California; top 36% in the U.S. |
| RN turnover (%) | 47.4 | 38.1 | 42.9 | bottom 31% in California; bottom 40% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.33, RN 0.81, weekend 3.92. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Borja, Jean | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/21/2019 |
| Borja, Jean | Individual | ADP of the SNF | NOT APPLICABLE | 11/21/2019 |
| Green-Rastekhiz, Emilee | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/14/2023 |
| Green-Rastekhiz, Emilee | Individual | ADP of the SNF | NOT APPLICABLE | 11/14/2023 |
| Hadrick, Stephany | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/05/2024 |
| Hadrick, Stephany | Individual | ADP of the SNF | NOT APPLICABLE | 09/05/2024 |
| Jackson, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2019 |
| Jackson, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/25/2026 |
| Jackson, Robert | Individual | Corporate Officer | NOT APPLICABLE | 03/20/2019 |
| Jackson, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/25/2026 |
| Khan, Alzeena | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/29/2024 |
| Khan, Alzeena | Individual | ADP of the SNF | NOT APPLICABLE | 09/23/2024 |
| McConnell, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2023 |
| McConnell, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 10/20/2023 |
| Roldan, Mary Rose | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/18/2020 |
| Roldan, Mary Rose | Individual | ADP of the SNF | NOT APPLICABLE | 05/18/2020 |
| Sandhu, Harkesh | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/19/2019 |
| Sandhu, Harkesh | Individual | ADP of the SNF | NOT APPLICABLE | 04/19/2019 |
| Sanofsky, Jack | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2019 |
| Sanofsky, Jack | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/25/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you handle room assignments and roommate requests, and do residents get advance written notice before any move?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Eskaton Village Care Center | 0.9 mi | Carmichael, CA | ★★★★☆ | 4/5 | |
| Sacramento Post-Acute | 1.1 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| American River Center | 1.1 mi | Carmichael, CA | ★★★★☆ | 4/5 | |
| Mission Carmichael Healthcare Center | 1.4 mi | Carmichael, CA | ★★★☆☆ | 3/5 | |
| Whitney Oaks Care Center | 1.4 mi | Carmichael, CA | ★★★☆☆ | 2/5 | |
| Manzanita Healthcare Center | 1.4 mi | Carmichael, CA | ★★★★★ | 3/5 | |
| Mountain Manor Senior Residence | 2.8 mi | Carmichael, CA | ★☆☆☆☆ | 2/5 | |
| River Pointe Post-Acute | 2.9 mi | Carmichael, CA | ★☆☆☆☆ | 2/5 | abuse |
| River City Post Acute | 2.9 mi | Carmichael, CA | ★☆☆☆☆ | 1/5 | abuse |
| Arden Park Post Acute | 3.8 mi | Sacramento, CA | ★★★☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 056158.