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Nursing HomeMedicaid Investigative

Grand Oaks Care

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

897 North M Street, Tulare, CA 9327499 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.8/5

based on 84 Google reviews

5
4
3
2
1
Grand Oaks Care Nursing Home in Tulare, CA — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

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

  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (21 vs median 13.0)

Below average in CA · Critically understaffed (RN) · Above recommended total nurse staffing · $34,492 in fines

Source: Medicare data

What this means for your family

This facility is an excellent choice for families seeking high-quality nursing care and a clean environment. While the staff is exceptionally well-regarded, you should verify that meal delivery temperatures are consistent and ask about any recent updates to flooring to ensure resident safety.

Google Reviews

Google Reviews

84 reviews on Google
Grand Oaks Care is highly regarded by families for its exceptionally compassionate and attentive nursing and CNA staff. While the facility is frequently praised for its cleanliness and professional rehabilitation services, some reviewers have noted concerns regarding food temperature and the need for floor updates to prevent tripping hazards.

Quality Themes

Tap a score for details
Food3.0Staff10.0Clean10.0Activities9.0Meds10.0MemoryN/AComms9.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Consistently clean and well-maintained facility
  • Effective and professional rehabilitation/physical therapy
  • Strong communication with family members

Concerns

  • Food temperature issues
  • Maintenance needs regarding floors and tripping hazards (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02024(2)4.92025(115)4.82026(16)

Distribution · 133 analyzed

5
119
4
13
3
0
2
1
1
0
28 reviews posted between Jan 14, 2025Jan 23, 2025 · 28 were 5-star
12 reviews posted between Jan 20, 2025Jan 23, 2025 · 12 were 5-star

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I noticed some families have shared how much they appreciate the communication from your team; how do you typically keep loved ones updated on daily changes in care?
  • 2What steps are being taken to ensure the dining experience, specifically regarding food temperature and meal variety, meets the needs of the residents?
  • 3Could you tell me about your current plan for addressing any facility maintenance or floor repairs to ensure a safe environment for walking?
  • 4How do you manage medical emergencies or changes in clinical needs during the overnight hours?
  • 5What kind of daily activities or social engagement programs do you have planned to keep residents active and connected?
  • 6With the recent focus on improving staffing and inspection scores, what specific changes has the facility implemented to support the nursing team?

Personalized based on this facility's data


Key Review Excerpts

I really appreciate this facility, for how all supervisor nurses /healthcare staff,very attentive caring and on task right away. At a difficult time as this.youll have made it better

Long-term resident's family · 2025★★★★★

The staff at Grand Oaks has been exceptional. They are kind and thoughtful. I recommend this facility for exceptional care.

Family member · 2025★★★★

My son is a Resident there it's going on 3 yrs.and all the NURSES THERE AND CNA'S WORK WELL WITH HIM HE'S NON - VERBAL AND THEY ALL TAKE THERE TIME TO UNDERSTAND HIM . AND GOOD WITH GIVING HIM HIS MEDICATION'S AS WELL.

Long-term resident's family · 2025★★★★★
Source: 84 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.39hrs
52%
Registered nurses for medical care
Total Nursing
4.10hrs
OK
All nurses + aides combined
Staff Turnover
50%
Lower is better (< 30% = good)
RN Turnover
30%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

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

Medicare Rating
4/ 5
Better Than Avg

10

measures

Worse Than Avg

1

measures

Mixed Results

6

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility3.1%
Better than Avg
Here
3.1%
US
15.4%
CA
11.6%
Tulare
7.0%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility18.9%
Mixed vs Avgs
Here
18.9%
US
19.4%
CA
10.7%
Tulare
12.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Tulare
99.6%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility16.0%
Worse than Avg
Here
16.0%
US
15.3%
CA
10.5%
Tulare
13.3%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility18.6%
Mixed vs Avgs
Here
18.6%
US
19.5%
CA
13.7%
Tulare
22.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility7.3%
Mixed vs Avgs
Here
7.3%
US
12.1%
CA
7.0%
Tulare
3.5%

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

Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
79.7%
CA
93.2%
Tulare
96.3%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.7%
Better than Avg
Here
99.7%
US
81.8%
CA
94.2%
Tulare
97.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.4%
Better than Avg
Here
0.4%
US
1.6%
CA
1.5%
Tulare
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
Near state avg (15.4)
22 complaint-triggered
$34,492 in fines

Families have filed complaints triggering 21 of 82 deficiencies, including repeated issues with notification of family members about resident injuries or changes. The most frequent problems involve care planning and quality standards, medication management, and food service issues. While all deficiencies show correction dates, the pattern of complaint-driven citations and recurring issues with family notification warrant careful consideration during visits.

Mar 12, 2026Complaint
1
0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

Feb 12, 2026Routine
11
0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

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.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services 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.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0032Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide primary/alternate means for communication.

Sep 2, 2025Complaint
1
0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Jul 29, 2025Complaint
1
0580Potential for harm · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Jul 3, 2025Complaint
1
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

May 9, 2025Complaint
1
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Grand Oaks Care

Organization Type

for profit

Chain Affiliation

Chain Name

Ajc Healthcare

Chain Size

14 facilities nationwide

Chain avg rating: 2.2/5 · Rank 8 of 13

Ownership & Management

Owners

Swc CA Opco 2 LLC

Owner · Organization

100%

Chesley, Aaron

Owner (parent company)

50%

Key personnel

Lawrence, MichelleW-2 Managing EmployeeChesley, AaronOfficer / DirectorGamett, JamesOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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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