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Nursing HomeMedicaid

College Oak Nursing & Rehabilitation Center

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

4635 College Oak Drive, Sacramento, CA 95841120 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 31 Google reviews

5
4
3
2
1
College Oak Nursing & Rehabilitation Center Nursing Home in Sacramento, CA — Street View
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What this means for your family

This facility is an excellent choice for rehabilitation, particularly for those needing physical or occupational therapy, as the clinical staff is highly rated. However, families should maintain frequent visits to monitor care and should be very proactive in communicating with administration regarding billing or lost personal items.

Google Reviews

Google Reviews

31 reviews on Google
Families can expect high-quality rehabilitation services and a compassionate nursing and therapy team, with several reviewers specifically praising the physical and occupational therapists. However, there are significant concerns regarding administrative communication, potential understaffing, and issues with the management of personal belongings like clothing.

Quality Themes

Tap a score for details
Food3.0Staff9.0Clean9.0ActivitiesN/AMedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Compassionate and attentive nursing and CNA staff
  • Excellent physical and occupational therapy services
  • Clean and well-maintained environment
  • Bilingual staff availability (Spanish)
  • Professional and skilled rehabilitation care

Concerns

  • Administrative communication and responsiveness (mentioned by 2 reviewers)
  • Staffing shortages and slow response times (mentioned by 2 reviewers)
  • Loss or mismanagement of patient belongings
  • Food quality and variety (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'19(1)'21(1)'23(2)'25(9)'26(6)

Distribution · 33 analyzed

5
19
4
4
3
2
2
1
1
7

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard wonderful things about your therapy team; could you tell us more about how the physical and occupational therapy programs are integrated into a resident's daily routine?
  • 2How does the administrative team ensure that families are kept updated and informed about changes in a resident's care plan?
  • 3What steps are in place to ensure that residents' personal belongings are organized and kept safe during their stay?
  • 4Could you describe the current meal service, including how much variety there is in the daily menu and how you handle specific dietary needs?
  • 5With the high praise for your nursing and CNA staff, how do you manage staffing levels during the night or on weekends to ensure response times remain quick?
  • 6What kind of social activities or group outings are available to help residents stay engaged with the community?

Personalized based on this facility's data


Key Review Excerpts

The staff are as a whole great, but you do have to visit your loved one often to make sure they're getting the care they need. The CNAs do good work and the nurses are alright. Sometimes they're understaffed.

Rehab patient's family · 2026★★★★

I was a patient at College Oak and I received the most awesome care from the CNA'S. To the Nursing staff, to the physical therapy, to the occupational therapy. They did an absolute fantastic job of taking care of me.

Former patient · 2025★★★★★

They washed and misplaced and gave away my brother’s clothes to other patients. They mix up all of the clothes there. Many patients complained of the same issues going on!

Long-term resident's family · 2025☆☆☆☆
Source: 31 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.76hrs
OK
Registered nurses for medical care
Total Nursing
4.45hrs
OK
All nurses + aides combined
Staff Turnover
43%
Lower is better (< 30% = good)
RN Turnover
57%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

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

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

2

measures

Mixed Results

7

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility21.5%
Worse than Avg
Here
21.5%
US
15.3%
CA
10.5%
Sacramento
8.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility3.9%
Better than Avg
Here
3.9%
US
15.5%
CA
11.7%
Sacramento
8.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.5%
Better than Avg
Here
1.5%
US
12.1%
CA
7.0%
Sacramento
5.2%

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

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.7%
Mixed vs Avgs
Here
9.7%
US
19.5%
CA
13.7%
Sacramento
8.7%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility11.5%
Mixed vs Avgs
Here
11.5%
US
19.4%
CA
10.7%
Sacramento
9.0%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility91.3%
Worse than Avg
Here
91.3%
US
95.5%
CA
98.2%
Sacramento
97.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility92.3%
Mixed vs Avgs
Here
92.3%
US
81.8%
CA
94.2%
Sacramento
98.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility87.9%
Mixed vs Avgs
Here
87.9%
US
79.8%
CA
93.2%
Sacramento
96.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.6%
Better than Avg
Here
0.6%
US
1.6%
CA
1.5%
Sacramento
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

7deficiencies
1penalties
Well below state avg (15.4)
5 complaint-triggered
$14,020 in fines

College Oak has concerning patterns with recurring medication management problems, fire safety issues, and infection control deficiencies appearing across multiple years. Five complaints from families triggered investigations, revealing issues with care quality, dietary accommodations, and resident transfers. While all deficiencies show correction dates, the repeated violations in critical areas like medication errors suggest ongoing operational challenges families should carefully consider.

Apr 9, 2026Routine
11
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0559Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

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.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0345Minimal · WidespreadCorrected

Smoke Deficiencies

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

Nov 20, 2025Complaint
2
0627Immediate jeopardy · IsolatedCorrected

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Feb 7, 2025Routine
15
0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

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.

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.

0814Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0640Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

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

Oct 24, 2024Complaint
1
0806Potential for harm · IsolatedCorrected

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.

Aug 6, 2024Complaint
1
0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

Feb 9, 2024Routine
7
0685Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

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

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Federal Penalties

Fine

Nov 20, 2025

$14,020

Ownership & Operations

Who Operates This Facility

Owner / Operator

College Oak Nursing & Rehabilitation Center

Organization Type

for profit

Chain Affiliation

Chain Name

Cypress Healthcare Group

Chain Size

13 facilities nationwide

Chain avg rating: 3.5/5 · Rank 6 of 13

Ownership & Management

Key personnel

Jackson, MatthewOfficer / DirectorJackson, RobertOfficer / DirectorSanofsky, JackOfficer / DirectorBorja, JeanManagerGreen-Rastekhiz, EmileeManager
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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