College Oak Nursing and Rehabilitation Center — Sacramento, CA
This page sets out what the federal inspection record says about College Oak Nursing and Rehabilitation Center, a 120-bed nursing home at 4635 College Oak Drive, Sacramento, California. Every figure below is copied from data the Centers for Medicare & Medicaid Services (CMS) publishes about nursing homes that take Medicare or Medicaid. We have not added our own judgment to it.
The record at a glance
| Federal ID (CCN) | 056158 |
| Legal business name | Spyglass, LLC |
| Listed chain or group | Cypress Healthcare Group |
| Address | 4635 College Oak Drive, Sacramento, CA 95841 |
| Phone listed with CMS | (916) 481-7434 |
| Ownership type | For profit – Limited Liability company |
| Certified beds | 120 |
| Average residents per day | 115.0 |
| Certified since | February 16, 1970 |
| Overall CMS rating | 3 out of 5 |
| Health inspection rating | 3 out of 5 |
| Staffing rating | 4 out of 5 |
| Quality measures rating | 4 out of 5 |
| Total nursing staff turnover | 40.0% |
| Most recent standard inspection | April 9, 2026 |
CMS scores nursing homes from one to five stars. The health inspection rating is set relative to other nursing homes in the same state, so a one-star home is in the bottom fifth in California, not the bottom fifth nationally. Staffing and quality measure ratings are scored against national thresholds.
Federal penalties
CMS’s penalty file lists 1 federal penalty against this facility: 1 fine totalling $9,814. A denial of payment means CMS stopped paying the home for residents admitted after a set date until the problem was fixed.
Inspectors have cited this home 24 times since January 2024
2 of those were at severity level G or above — what CMS calls actual harm. 1 reached immediate jeopardy, CMS’s most serious category. 5 came from complaints rather than routine inspections. Every one of them is listed below, with its date and what the rule required.
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Inspection citations since January 2024
CMS records 24 health citations at this facility from inspections between February 9, 2024 and May 29, 2026.
| Inspected | Tag | What the rule requires | Scope and severity | Status |
|---|---|---|---|---|
| May 29, 2026 | F0628 | Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies. (complaint) | D — Isolated, Potential for more than minimal harm | Correction date Jun 10, 2026 |
| Apr 9, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F — Widespread, Potential for more than minimal harm | Correction date Apr 24, 2026 |
| Apr 9, 2026 | F0559 | Honor the resident’s right to share a room with spouse or roommate of choice and receive written notice before a change is made. | D — Isolated, Potential for more than minimal harm | Correction date Apr 24, 2026 |
| Apr 9, 2026 | F0697 | Provide safe, appropriate pain management for a resident who requires such services. | D — Isolated, Potential for more than minimal harm | Correction date Apr 24, 2026 |
| Apr 9, 2026 | F0761 | 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. | D — Isolated, Potential for more than minimal harm | Correction date Apr 24, 2026 |
| Apr 9, 2026 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D — Isolated, Potential for more than minimal harm | Correction date Apr 24, 2026 |
| Nov 20, 2025 | F0627 | Ensure the transfer/discharge meets the resident’s needs/preferences and that the resident is prepared for a safe transfer/discharge. (complaint) | J — Isolated, Immediate jeopardy | Correction date Nov 25, 2025 |
| Feb 9, 2024 | F0685 | Assist a resident in gaining access to vision and hearing services. | G — Isolated, Actual harm | Correction date Feb 23, 2024 |
The wording in the third column is CMS’s own plain-language summary of the federal rule that was cited, not a description of what happened. This table shows every one of the 2 citations at actual-harm level or above, plus the 6 most recent of the rest. The other 16 are in the CMS file linked below.
How to read scope and severity
Every citation gets a letter from A to L. The letter carries two things at once: how serious the problem was, and how many residents it reached.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J | K | L |
| Actual harm | G | H | I |
| No actual harm, potential for more than minimal harm | D | E | F |
| No actual harm, potential for minimal harm | A | B | C |
“Immediate jeopardy” is CMS’s term for a situation that has caused, or is likely to cause, serious injury, harm, impairment or death. It requires the home to act at once.
What this page does not tell you
- A citation is an inspector’s finding against a federal rule. It is not a court judgment, and the facility may be disputing it. Citations marked “under dispute” above are in CMS’s formal review process.
- Citation counts partly reflect how often a home was inspected and how many complaints were filed about it. A home with more citations has not automatically given worse care than one with fewer.
- Bigger homes have more residents, more staff and more inspections, so they tend to accumulate more citations.
- None of this says anything about the care any one resident received. A home with a clean record can still fail somebody, and a home with a bad record can be caring for your mother well.
- This is a snapshot. CMS updates these files monthly, and the figures here are from the file dated August 1, 2026.
Where this comes from
- Ratings, ownership, beds and penalties: CMS Provider Information dataset (4pq5-n9py), file dated August 1, 2026.
- Citations: CMS Health Deficiencies dataset (r5ix-sfxw), file dated August 1, 2026, filtered to inspections on or after January 1, 2024.
- This facility on the government’s own site: Medicare Care Compare.
- Retrieved August 29, 2026. Our method is set out in Editorial policy and How we count.
For the facility
If anything on this page is wrong, out of date or missing context, we will correct it. College Oak Nursing and Rehabilitation Center and anyone acting for it can reach the watchdog team through our corrections and right of reply page. We publish the response alongside the record.
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