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Nursing HomeMedicaid Investigative

Blue Oak Post-Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

850 Sonoma Ave, Santa Rosa, CA 95404181 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.3/5

based on 10 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Above-median deficiencies (26 vs median 13.0)

Below average in CA · Below recommended RN staffing · Low staff turnover (stable workforce) · $51,518 in fines · Abuse citation

Source: Medicare data

What this means for your family

This facility is an excellent choice if your primary concern is finding a kind, professional, and communicative care team. However, you should proactively inquire about the meal program and the availability of fresh produce to ensure it meets your loved one's nutritional needs.

Google Reviews

Google Reviews

10 reviews on Google
Families can expect a highly compassionate and attentive nursing staff that prioritizes resident dignity and emotional well-being. While the facility is praised for its welcoming atmosphere and professional care, there are significant concerns regarding the quality and freshness of the food provided.

Quality Themes

Tap a score for details
Food1.0Staff10.0Clean5.0ActivitiesN/AMedsN/AMemoryN/AComms10.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Clean and well-maintained facility
  • Clear and consistent family communication
  • Person-centered, dignified care

Concerns

  • Inadequate food quality and lack of fresh fruit

Rating Trends

Tap a year to see what changed

Distribution · 15 analyzed

5
12
4
0
3
0
2
1
1
2

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I've heard wonderful things about your nursing staff being very compassionate; how do you ensure that level of attentive care is maintained during shift changes?
  • 2Could you tell me a bit about the daily dining experience, specifically regarding the variety of meals and the availability of fresh fruit?
  • 3With the high staffing rating you have, how does that extra support translate into personalized care for each resident's specific needs?
  • 4What is the protocol for handling medical emergencies or sudden changes in a resident's health during the night?
  • 5What kind of daily activities or social programs are available to keep residents engaged and connected with one another?
  • 6How does the facility work with families to ensure we are kept informed and involved in our loved one's care plan?

Personalized based on this facility's data


Key Review Excerpts

The team is incredibly attentive, responsive, and genuinely understanding of each patient’s unique needs.

Patient's family · 2026★★★★★

The nurses and staff are not only highly skilled, but also incredibly compassionate and attentive.

Resident's family · 2026★★★★★

Communication with families is clear and consistent, which brings great peace of mind.

Resident's family · 2026★★★★★
Source: 10 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.57hrs
77%
Registered nurses for medical care
Total Nursing
3.70hrs
90%
All nurses + aides combined
Staff Turnover
19%
Lower is better (< 30% = good)
RN Turnover
26%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

4

measures

Mixed Results

4

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility26.7%
Worse than Avg
Here
26.7%
US
15.4%
CA
11.6%
Sonoma
10.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility27.7%
Worse than Avg
Here
27.7%
US
19.5%
CA
13.7%
Sonoma
14.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.4%
Better than Avg
Here
3.4%
US
12.1%
CA
7.0%
Sonoma
4.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility11.3%
Mixed vs Avgs
Here
11.3%
US
19.4%
CA
10.7%
Sonoma
14.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.7%
Better than Avg
Here
7.7%
US
15.3%
CA
10.5%
Sonoma
11.6%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.7%
Better than Avg
Here
7.7%
US
14.4%
CA
10.4%
Sonoma
8.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility79.6%
Worse than Avg
Here
79.6%
US
81.8%
CA
94.2%
Sonoma
96.7%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility85.9%
Mixed vs Avgs
Here
85.9%
US
79.7%
CA
93.2%
Sonoma
94.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
CA
1.5%
Sonoma
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

25deficiencies
2penalties
Well above state avg (15.4)
20 complaint-triggered
$51,518 in fines

This facility has serious and recurring safety concerns, with families filing multiple complaints about abuse and neglect protection failures across several years. The primary problem areas are protecting residents from abuse and neglect, fire safety systems, and medication management. While the facility corrects violations when cited, the same serious issues keep appearing in new complaints, suggesting persistent systemic problems rather than isolated incidents.

Jan 7, 2026Complaint
2
0609Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Dec 22, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Dec 11, 2025Complaint
2
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Nov 25, 2025Routine
22
0037Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0583Potential for harm · PatternCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0805Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

0806Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0919Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Sep 8, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Jul 22, 2025Complaint
3
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

Federal Penalties

Fine

Dec 11, 2025

$28,106

Fine

Jan 7, 2025

$8,278

Ownership & Operations

Who Operates This Facility

Owner / Operator

Blue Oak Post-Acute

Organization Type

for profit

Ownership & Management

Owners

Jose, Josekutty

Owner

Key personnel

Jose, JosekuttyOfficer / DirectorJose, JosekuttyOfficer / DirectorMatalon, EranManagerRose, MeganManagerSuratos, RaulManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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