College Oak Nursing & Rehabilitation Center
Nursing Home Facility
4635 College Oak Drive, Sacramento, CA 95841
College Oak Nursing & Rehabilitation Center is a senior care community located in Sacramento, CA. It provides nursing home care and senior living for older adults in the Sacramento area. To learn more or schedule a tour, call (916) 481-7434.
Operated by Cypress Healthcare Group, which runs 12 communities in our directory.
With 120 beds, College Oak Nursing & Rehabilitation Center is one of the larger communities in the area, senior care communities in Sacramento average about 17 beds. Larger communities more often keep clinical staff on site around the clock and can offer a wider range of on-site therapy and activities, though some families prefer the quieter feel of a smaller setting.
Federal reporting puts occupancy at about 96% of its licensed beds, which is high; communities this full often maintain a waiting list, so it is worth calling well before you need a place.
Medicare rates this community 3 out of 5 stars overall, a score based on health inspections, staffing levels and quality measures. Its most recent standard health inspection was in April 2026 and recorded 8 deficiencies.
Residents receive about 4.3 hours of nursing care per day on average, including 0.8 hours from a registered nurse. Nursing staff turnover over the past year was about 40%.
The community is located in Sacramento County, CA.
Inspection record
In its last three standard inspections and any complaint visits, federal inspectors cited 25 problems at College Oak Nursing & Rehabilitation Center. 2 findings involved harm to a resident, including 1 that put residents in immediate danger. 6 came from investigating complaints by residents or families.
In the last three years Medicare fined this home once, a total of $9,814.
Findings from the most recent inspection cycle
-
Put residents in immediate danger, one or a few residents
Resident Rights
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
-
Could cause more than minimal harm, one or a few residents
Resident Rights
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
-
Could cause more than minimal harm, widespread
Nutrition and Dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
-
Could cause more than minimal harm, one or a few residents
Resident Rights
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
-
Could cause more than minimal harm, one or a few residents
Quality of Life and Care
Provide safe, appropriate pain management for a resident who requires such services.
-
Could cause more than minimal harm, one or a few residents
Pharmacy Service
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.
-
Could cause more than minimal harm, one or a few residents
Resident Assessment and Care Planning
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
-
Could cause more than minimal harm, one or a few residents
Resident Rights
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
A citation on its own does not mean poor care, and most are corrected within weeks. What matters most is how serious the findings were and whether the same problems keep coming back. When you visit, it is fair to ask the administrator what inspectors found and what has changed since.
College Oak Nursing & Rehabilitation Center offers nursing home care and senior living.
Facility details
- Organization type for-profit corporation
- Beds / units 120
- Occupancy 96%
- Nursing hours per resident/day 4.3
- Annual staff turnover 40%
- Last health inspection April 2026
Resident & family reviews
When this nursing home went into lockdown, our family couldn’t monitor our mothers care as closely. In the few weeks that we were not allowed to visit her, she had rapid weight loss and a wound on her hand that was not reported to the family. During lock down, she contracted covid, days after she was rushed to the hospital because she was unresponsive. At the hospital, the nurse responsible for our mother's care mentioned that there were signs of neglect. Our mother didn’t appear to have been bathed in a while and the wound on her hand had not been properly cared for. Her hand was covered in yeast, which indicated that they had not been cleaning that area. This nursing home is deceptively appealing, but you don’t know what is happening behind closed doors. If you love your family member, do not leave them in this place.
by Liz C., Jan 2022