College Oak Nursing and Rehabilitation Center
4635 College Oak Drive, Sacramento, CA 95841
College Oak Nursing and Rehabilitation Center is a nursing home in Sacramento, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating4 of 5
- Last standard health inspectionApril 9, 2026 (7 months ago)
- Health citations since October 5, 202326 (California average 50)
- Fines in the past three years1, $9,814 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 12, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0628 3 times since 2025.
CMS update of July 29, 2026
Fine
CMS changed the fine from November 20, 2025 from $14,020 to $9,814.
CMS update of June 24, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Name
CMS lists a new name for this home. It was COLLEGE OAK NURSING & REHABILITATION CENTER.
Health inspection on May 29, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on June 10, 2026.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
Health inspection on April 9, 2026
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for F0812 2 times since 2025.
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on April 24, 2026.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 24, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for F0761 2 times since 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 24, 2026.
Fire safety inspection on April 9, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on April 24, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 24, 2026.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0363 2 times since 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 24, 2026.
Citation K0345. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 24, 2026.
Health inspection on November 20, 2025
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
86 of 1,165 California homes (7%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $9,814 on November 20, 2025.
Show the 2 citations
Citation F0627. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS lists it as corrected on November 25, 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on November 25, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Health inspection on February 7, 2025
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 28, 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 28, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 28, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 28, 2025.
Citation F0814. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on February 28, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 28, 2025.
CMS has cited this home for F0880 2 times since 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on February 28, 2025.
Citation F0640. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on February 28, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 28, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on February 28, 2025.
CMS has cited this home for F0658 2 times since 2024.
Fire safety inspection on February 7, 2025
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 21, 2025.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on February 21, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 21, 2025.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on February 21, 2025.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 21, 2025.
CMS has cited this home for K0918 2 times since 2024.
Health inspection on October 24, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on November 4, 2024.
Health inspection on August 6, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 10, 2024.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of March 28, 2024
Fine
CMS changed the fine from May 13, 2021 from $5,735 to $3,728.
Health inspection on February 9, 2024
4 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.
Show the 4 citations
Citation F0685. Severity G: actual harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on February 23, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on February 23, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 23, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 23, 2024.
Fire safety inspection on February 9, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 27, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 27, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 27, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on October 5, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 20, 2023.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (916) 481-7434
- Last standard health inspection
- April 9, 2026 (7 months ago)
- Certified beds
- 120
- Residents per day, on average
- 113.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Spyglass, LLC
- Chain
- Cypress Healthcare Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (26 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BORJA, JEANOperational/managerial control · not applicable · since 11/21/2019
- GREEN-RASTEKHIZ, EMILEEOperational/managerial control · not applicable · since 11/14/2023
- HADRICK, STEPHANYOperational/managerial control · not applicable · since 09/05/2024
- JACKSON, MATTHEWOperational/managerial control · not applicable · since 06/25/2026
- JACKSON, ROBERTOperational/managerial control · not applicable · since 06/25/2026
Show 7 more
- KHAN, ALZEENAOperational/managerial control · not applicable · since 09/29/2024
- MCCONNELL, CHRISTOPHEROperational/managerial control · not applicable · since 10/20/2023
- ROLDAN, MARY ROSEOperational/managerial control · not applicable · since 05/18/2020
- SANDHU, HARKESHOperational/managerial control · not applicable · since 04/19/2019
- SANOFSKY, JACKOperational/managerial control · not applicable · since 06/25/2026
- SINGH, SHALINIOperational/managerial control · not applicable · since 12/13/2022
- WATKINS, MICHAELOperational/managerial control · not applicable · since 06/28/2022
Questions
When was College Oak Nursing and Rehabilitation Center last inspected?
CMS lists April 9, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does College Oak Nursing and Rehabilitation Center have?
CMS lists 26 health citations since October 5, 2023. CMS also calls these deficiencies.
Has College Oak Nursing and Rehabilitation Center been fined?
CMS lists 1 fine in the past three years, $9,814 in total.
What is the CMS star rating of College Oak Nursing and Rehabilitation Center?
Its CMS overall star rating is 4 of 5.
Is College Oak Nursing and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.