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Nursing homeFAID #1059

College Oak Nursing and Rehabilitation Center

4635 COLLEGE OAK DRIVE, SACRAMENTO, CA, 95841
(916) 481-7434
120 licensed beds

CMS rates College Oak Nursing and Rehabilitation Center 4 out of 5 overall. Federal inspectors issued 40 citations across 12 inspections in the last three years, with $9,814 in fines. Listing last updated 2026-11-06.

★★★★★4/5CMS Five-Star overall3/5 health inspections4/5 staffing5/5 quality measuresSource: CMS Care Compare

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Photo of College Oak Nursing and Rehabilitation Center
Photo via Google · Nathaniel Demian-Duncan

Address

4635 College Oak Drive
Sacramento, CA 95841
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What we can show you for free.
Bed capacity
120
CMS facility ID
056158
Care type
Nursing home
County
Sacramento
Facility name
College Oak Nursing and Rehabilitation Center
Street address
4635 COLLEGE OAK DRIVE
City / state / ZIP
Sacramento, CA 95841
Phone
(916) 481-7434

College Oak Nursing and Rehabilitation Center is a Medicare/Medicaid-certified skilled nursing facility in Sacramento, California. It is licensed for 120 beds — above the median for skilled nursing facilities in California (98 beds).

It is one of 317 senior care facilities in Sacramento and 1,165 skilled nursing facilities across California. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.

It is listed as part of Cypress Healthcare Group, a group of 13 facilities on this site.

Federal inspectors have cited College Oak Nursing and Rehabilitation Center 40 times across 12 inspections in the last three years, including 4 food-safety citations, and CMS has imposed $9,814 in fines. Every citation is listed, dated, and graded in the inspection record below.

This listing draws on federal CMS Nursing Home Compare records, and was last updated on November 6, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.

What the public record shows.

Ownership & operator

Parent company
Cypress Healthcare Group
Ownership type
For profit - Limited Liability company

Registered owners & officers

Borja, Jean
Operational control · Additional disclosable party — since 2019
Green-rastekhiz, Emilee
Operational control · Additional disclosable party — since 2023
Hadrick, Stephany
Operational control · Additional disclosable party — since 2024
Jackson, Matthew
Officer · Operational control — since 2019
Jackson, Robert
Officer · Operational control — since 2019
Khan, Alzeena
Operational control · Additional disclosable party — since 2024
Mcconnell, Christopher
Operational control · Additional disclosable party — since 2023
Roldan, Mary Rose
Operational control · Additional disclosable party — since 2020
Sandhu, Harkesh
Operational control · Additional disclosable party — since 2019
Sanofsky, Jack
Officer · Operational control — since 2019
Singh, Shalini
Operational control · Additional disclosable party — since 2022
Watkins, Michael
Operational control · Additional disclosable party — since 2022

Regulatory standing

Licensed / certified since
1970-02-16
CMS overall rating
4 of 5 stars
Health deficiencies
9 at the last standard inspection
Federal fines
$9,814 total
Last standard inspection
2026-04-09
Nurse staffing
4.3 hours per resident per day

Cost & payer profile (FY2023 cost report)

Average billed charges
$328 per day (≈ $9,970/month). Private-pay prices typically track billed charges; Medicare and Medicaid pay set rates.
Payer mix (resident days)
65% Medicaid · 17% Medicare · 18% private/other
Occupancy
91% (fiscal year 2023)
Vs. state median
36% below the CA median of $514/day — full state cost breakdown

Services & coverage

Licensed beds
120
Medicare
Accepted
Medicaid
Accepted
Wheelchair accessible
entrance and parking
Visiting hours
Daily Open 24 hours
Compiled from CMS Nursing Home Compare; owners/officers from the CMS Ownership dataset; cost & occupancy from the facility's own CMS cost report; hours/accessibility via Google · last verified 2026-11-06. Facilities can submit a correction.
Every citation, dated and graded.

Kitchen & food safety

Federal surveyors inspect the kitchen at every standard visit. This facility has 4 food-safety citations on its three-year record — flagged below among the inspections.
2026-08-12Health inspectionComplaint-triggered1 citation
F-0628
D · No harm foundFrom a complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-08-28
2026-05-29Health inspectionComplaint-triggered1 citation
F-0628
D · No harm foundFrom a complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-06-10
10 earlier / fire-safety inspections (38 citations)
2026-04-09Health inspection5 citations
F-0559
D · No harm found
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-04-24
F-0697
D · No harm found
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-04-24
F-0761
D · No harm found
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.
Corrected 2026-04-24
F-0812
F · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-04-24
F-0842
D · No harm found
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-04-24
2025-11-20Health inspectionComplaint-triggered2 citations
F-0627
J · Immediate jeopardyFrom a complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-11-25
F-0628
D · No harm foundFrom a complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-25
2025-02-07Health inspection10 citations
F-0558
D · No harm found
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-28
F-0640
D · No harm found
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-28
F-0656
D · No harm found
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-28
F-0658
D · No harm found
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-28
F-0755
E · No harm found
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
F-0759
E · No harm found
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-28
F-0761
E · No harm found
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.
Corrected 2025-02-28
F-0812
E · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
F-0814
E · No harm foundFood safety
Dispose of garbage and refuse properly.
Corrected 2025-02-28
F-0880
E · No harm found
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
2024-10-24Health inspectionComplaint-triggered1 citation
F-0806
D · No harm foundFood safetyFrom a complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-11-04
2024-08-06Health inspectionComplaint-triggered1 citation
F-0658
D · No harm foundFrom a complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-10
2024-02-09Health inspection4 citations
F-0679
D · No harm found
Provide activities to meet all resident's needs.
Corrected 2024-02-23
F-0685
G · Actual harm
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-23
F-0759
D · No harm found
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-23
F-0880
D · No harm found
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
2023-10-05Health inspectionComplaint-triggered1 citation
F-0684
D · No harm foundFrom a complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
2026-04-09Fire-safety inspection6 citations
K-0345
C · No harm found
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-04-24
K-0353
D · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-04-24
K-0355
D · No harm found
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-04-24
K-0363
D · No harm found
Install corridor and hallway doors that block smoke.
Corrected 2026-04-24
K-0374
E · No harm found
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-04-24
K-0920
D · No harm found
Ensure proper usage of power strips and extension cords.
Corrected 2026-04-24
2025-02-07Fire-safety inspection5 citations
K-0161
D · No harm found
Use approved construction type or materials.
Corrected 2025-02-21
K-0353
D · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-21
K-0363
E · No harm found
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
K-0711
D · No harm found
Provide a written emergency evacuation plan.
Corrected 2025-02-21
K-0918
D · No harm found
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-21
2024-02-09Fire-safety inspection3 citations
K-0321
D · No harm found
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-27
K-0353
E · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-27
K-0918
F · No harm found
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-27

Federal penalties

2025-11-20Fine$9,814
Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 056158.
How it compares in California.
Inspection citations, 3 years
40
More than 15% of nursing homes in the state
State median: 65
Federal fines, 3 years
$9,814
More than 67% of nursing homes in the state
State median: $0
Nurse staffing, hours per resident per day
4.3
Higher than 51% of nursing homes in the state
State median: 4.3
Nursing staff turnover, annual
37%
Higher than 53% of nursing homes in the state
State median: 36%

Resident outcomes

On 21 federal quality measures, this facility does better than the California average on 8 and worse on 6. Differences within 10% of the average are shown as near average.

Long-stay residentsThis facilityStateUSCompared with state
Need for help with daily activities has increased12.5%10.2%13.5%Worse than state
Lose too much weight6.5%4.1%5.1%Worse than state
With a catheter inserted and left in their bladder0.0%0.7%0.7%Better than state
With a urinary tract infection1.0%1.2%1.5%Better than state
Have depressive symptoms1.4%7.6%13.5%Better than state
Were physically restrained0.0%0.3%0.1%Better than state
Experiencing one or more falls with major injury1.6%1.6%3.2%Near state average
Assessed and appropriately given the pneumococcal vaccine99.7%98.7%93.7%Near state average
Ability to walk independently worsened17.8%8.9%12.7%Worse than state
Received an antianxiety or hypnotic medication8.5%13.7%19.5%Better than state
Assessed and appropriately given the seasonal influenza vaccine89.8%97.9%95.3%Near state average
With pressure ulcers4.1%4.3%4.5%Near state average
With new or worsened bowel or bladder incontinence11.3%9.8%18.3%Worse than state
Received an antipsychotic medication4.9%12.3%15.4%Better than state
Hospitalizations per 1000 long-stay resident days2.502.211.81Worse than state
Outpatient emergency department visits per 1000 long-stay resident days1.491.501.69Near state average
Short-stay residentsThis facilityStateUSCompared with state
Assessed and appropriately given the pneumococcal vaccine92.0%94.6%82.3%Near state average
Newly received an antipsychotic medication0.2%1.3%1.5%Better than state
Were assessed and appropriately given the seasonal influenza vaccine91.7%93.1%80.1%Near state average
Were rehospitalized after a nursing home admission19.3%22.6%23.4%Better than state
Had an outpatient emergency department visit12.6%11.1%11.8%Worse than state
Source: CMS MDS and Medicare claims quality measures, measure period 2025Q3-2026Q2. Averages are computed from all nursing homes reporting each measure.

Cited more than once

The same rule cited at separate inspections can point to a problem that wasn't fully fixed.

  • F-0628 3 inspections. Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  • K-0353 3 inspections. Inspect, test, and maintain automatic sprinkler systems.
  • F-0761 2 inspections. 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.
  • F-0812 2 inspections. Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  • K-0363 2 inspections. Install corridor and hallway doors that block smoke.
  • F-0658 2 inspections. Ensure services provided by the nursing facility meet professional standards of quality.
Where to check, and what's nearby.

Who to contact in California

  • Licensing: California Department of Public Health, Center for Health Care Quality, Licensing and Certification
  • File a complaint: 844-538-8766 · Online
  • Long-Term Care Ombudsman: 800-231-4024. A free advocate for residents and families.
  • Adult Protective Services: 833-401-0832. Some states send facility cases to licensing instead. In an emergency, call 911.
  • Eldercare Locator: 800-677-1116, a federal service for local aging help.

Nearest emergency hospitals

  • Heritage Oaks Hospital, about 0.9 miles.
  • Mercy San Juan Medical Center, about 2.3 miles. CMS rating 3 of 5.
  • Kaiser Foundation Hospital - Sacramento, about 4.0 miles. CMS rating 4 of 5.
Source: CMS Hospital General Information. Straight-line distance.

Nearby facilities with inspection records

What people say on Google.
4.264 ratings on Google
★Urma Mohamen · 2026-06-11 · via Google

“I do not recommend this place. It used to seem like the administrator didn't care much, but now everything is wrong. The food has been horrible for the past two months. Miranda, the kitchen assistant, is very rude and completely unprofessional; I have heard her yelling at residents more than once simply because they asked for something from the kitchen. It isn't right—don't leave your loved ones h…”

★★★Wendie Lindsay · 2026-05-25 · via Google

“There is not enough parking spaces, ever! The employees are doubling up their cars, in single car spaces, nowhere for guest to park & rarely is the 1 handicapped space available! The place is very nice, there is a fountain @ entrance, lots of ftiendly & rude staff! I would recommend it, but I must warn, my client, a brain cancer patient, had about $80 in twenties stolen out of her purse, while a p…”

★★Kelly Rodriguez · 2026-05-20 · via Google

“Having been there to see a friend. I wanted to touch base with the administrator, Chris, I was told he was in a meeting, so the Assistant Administrator, Nick, took 2 minutes .Said he would get her chart and come on down to the room. One hour later nobody came. Went back up front. No Nick in sight. Asked to speak with a case worker or P.T. all at lunch at 1:45. At the one hour mark p.t. and a case …”

Ratings and reviews are from Google and reflect visitor opinions, not our verification. See all reviews on Google
What unlocks when you order.

Ownership & corporate history

Primary tier
Prior operators & transfers
Corporate network & affiliates
,
Owners' other facilities
· · 2 more

Inspection citations — last 5 years

Locked
The 40 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.

Civil & criminal lawsuits

Advanced tier only
Active civil suits
#
Federal dockets
CDC infection data
Unlock the full file
Citations, owner history, lawsuits — decoded into one PDF.
Sources we pull for this facility.
Source
CMS Nursing Home Compare
data.cms.gov Provider Data Catalog
Last verified 2026-11-06
Source
Google Business Profile
Photos, reviews & hours
Displayed with attribution · refreshed on re-run
Source
Secretary of State filings
Entity & officer search
Pulled when a report is ordered
Source
PACER federal dockets
pacer.uscourts.gov
Pulled when a report is ordered