Fair Oaks Healthcare Center
11300 Fair Oaks Boulevard, Fair Oaks, CA 95628 · Sacramento County · 149 certified beds · avg 144 residents/day · certified since Jul 1, 1983
Part of chain: CYPRESS HEALTHCARE GROUP (13 facilities, chain avg rating 3.8★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$8,990
Fines, last 3 years
4.63
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · 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)
▲ Actual harm, one-off · Jun 6, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Jul 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 2024 · F-0687 · triggered by a complaint
The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
Why it matters: Neglected feet can develop painful sores and infections, especially dangerous for residents with diabetes.
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: Apr 17, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (55)
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 |
|---|---|---|
| Jul 2, 2026 | 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 |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Feb 13, 2026 | 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 13, 2026 | E · Potential for harm, repeated | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Feb 13, 2026 | 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 13, 2026 | 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 13, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Feb 13, 2026 | 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. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Sep 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 8, 2025 | 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 |
| Jan 8, 2025 | 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. · from a complaint |
| Oct 18, 2024 | 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. |
| Oct 18, 2024 | 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. |
| Oct 18, 2024 | 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. |
| Oct 18, 2024 | 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. |
| Oct 18, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 18, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Oct 18, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 16, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 6, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not make sure resident assessments were done by a qualified health professional. Assessments guide all of a resident's care, so the person doing them must be properly trained. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jun 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 |
| Mar 21, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Mar 21, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Mar 21, 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. · from a complaint |
| Feb 8, 2024 | F · Potential for harm, facility-wide | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jan 17, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 17, 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 |
| Dec 29, 2023 | 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 |
| Dec 21, 2023 | 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. · from a complaint |
| Oct 30, 2023 | 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 |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | 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. |
| Nov 4, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 4, 2021 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 10 | 0 | E |
| 2023 | 3 | 0 | D |
| 2024 | 19 | 2 | G ▲ |
| 2025 | 5 | 0 | D |
| 2026 | 18 | 0 | E |
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 $8,990.
| Date | Type | Amount / length |
|---|---|---|
| Jun 6, 2024 | Fine | $8,990 |
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) | 4.63 | 4.31 | 3.95 | top 24% in California; top 20% in the U.S. |
| Registered Nurse hours | 0.74 | 0.61 | 0.69 | top 21% in California; top 32% in the U.S. |
| Weekend total nurse staffing | 4.28 | 3.90 | 3.50 | top 21% in California; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.56 | 0.51 | 0.48 | top 25% in California; top 27% in the U.S. |
| Total nursing staff turnover (%) | 30.4 | 36.7 | 45.8 | top 30% in California; top 15% in the U.S. |
| RN turnover (%) | 28.6 | 38.1 | 42.9 | top 33% in California; top 26% 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 4.36, RN 0.70, weekend 4.03. Staffing rating: 5/5.
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: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cypress Healthcare Group LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/29/2023 |
| Bernt, Brandon | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/06/2024 |
| Bernt, Brandon | Individual | ADP of the SNF | NOT APPLICABLE | 02/06/2024 |
| Christian, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/03/2024 |
| Christian, Amber | Individual | ADP of the SNF | NOT APPLICABLE | 04/03/2024 |
| Dale, Lawanda | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/29/2023 |
| Dale, Lawanda | Individual | ADP of the SNF | NOT APPLICABLE | 11/29/2023 |
| Dhir, Sunil | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2023 |
| Dhir, Sunil | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2023 |
| Evans, Kalesia | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/21/2024 |
| Evans, Kalesia | Individual | ADP of the SNF | NOT APPLICABLE | 10/21/2024 |
| Garland, Myrna | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/16/2024 |
| Garland, Myrna | Individual | ADP of the SNF | NOT APPLICABLE | 08/16/2024 |
| Jackson, Alec | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/29/2023 |
| Jackson, Alec | Individual | ADP of the SNF | NOT APPLICABLE | 09/29/2023 |
| Jackson, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 09/29/2023 |
| Jackson, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/29/2023 |
| Jackson, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 09/29/2023 |
| Jackson, Robert | Individual | Corporate Officer | NOT APPLICABLE | 09/29/2023 |
| Jackson, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/29/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How is routine foot care handled here, and does a podiatrist visit regularly?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who oversees residents' therapeutic diets, and how do the doctor and dietitian work together on them?"
- "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 |
|---|---|---|---|---|---|
| Citrus Heights Post Acute | 1.3 mi | Citrus Heights, CA | ★★★★☆ | 3/5 | |
| Manzanita Healthcare Center | 3.8 mi | Carmichael, CA | ★★★★★ | 3/5 | |
| Sacramento Post-Acute | 4.3 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| American River Center | 4.6 mi | Carmichael, CA | ★★★★☆ | 4/5 | |
| Casa Coloma Health Care Center | 4.6 mi | Rancho Cordova, CA | ★★☆☆☆ | 2/5 | |
| College Oak Nursing and Rehabilitation Center | 4.9 mi | Sacramento, CA | ★★★☆☆ | 3/5 | |
| Mountain Manor Senior Residence | 4.9 mi | Carmichael, CA | ★☆☆☆☆ | 2/5 | |
| River Pointe Post-Acute | 4.9 mi | Carmichael, CA | ★☆☆☆☆ | 2/5 | abuse |
| River City Post Acute | 5.0 mi | Carmichael, CA | ★☆☆☆☆ | 1/5 | abuse |
| Roseville Care Center | 5.1 mi | Roseville, CA | ★★★☆☆ | 2/5 | abuse |
| Eskaton Village Care Center | 5.1 mi | Carmichael, CA | ★★★★☆ | 4/5 | |
| Pine Creek Care Center | 5.1 mi | Roseville, CA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555153.