Facility WatchInspection records for every certified US nursing home
College Oak Nursing and Rehabilitation Center
4635 College Oak Drive Sacramento, CA 95841 (916) 481-7434
CCN
056158
Certified beds
120
Ownership
For profit - Limited Liability company
Chain
Cypress Healthcare Group
Nurse staffing
4.43
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.76 hours per resident per day
Nursing staff turnover: 43% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 9, 2026
5 citations · Health
D
F0559No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Deficient, Provider has date of correction · corrected April 24, 2026
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 24, 2026
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 24, 2026
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 24, 2026
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 24, 2026
Inspected November 20, 2025
2 citations · from a complaint investigation · Health
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected November 25, 2025
J
F0627Immediate jeopardy to resident health or safety · Isolated
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Deficient, Provider has date of correction · corrected November 25, 2025
Inspected February 7, 2025
10 citations · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected February 28, 2025
D
F0640No actual harm with potential for more than minimal harm · Isolated
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Deficient, Provider has date of correction · corrected February 28, 2025
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected February 28, 2025
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0814No actual harm with potential for more than minimal harm · Pattern
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected February 28, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 28, 2025
Inspected October 24, 2024
1 citation · from a complaint investigation · Health
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected November 4, 2024
Inspected August 6, 2024
1 citation · from a complaint investigation · Health
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected September 10, 2024
Inspected February 9, 2024
4 citations · Health
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected February 23, 2024
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 23, 2024
G
F0685Actual harm · Isolated
Assist a resident in gaining access to vision and hearing services.
Deficient, Provider has date of correction · corrected February 23, 2024
Inspected October 5, 2023
1 citation · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected October 20, 2023
Penalties
Date
Type
Amount
November 20, 2025
Fine
$14,020
Ownership transfers
Effective
Seller
Buyer
03/20/2019
C.o.n.r., Inc.
Spyglass, LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.