Nursing homes › California › Grand Oaks Care
897 North M Street, Tulare, CA 93274 · 5596871340 · 99 certified beds
Per CMS filings, this facility is affiliated with Ajc Healthcare, a group operating 14 facilities in 1 states. Group record: average rating 2.2/5, 5 abuse citation icons, 2 facilities on the Special Focus list, $830,489 in federal fines. This facility rates above its group average (2.2/5).
Total nurse staffing: 4.25 (California median: 4.24). RN hours: 0.34. Weekend total: 3.81. Nursing staff turnover: 50%.
All-time on record: 55 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-03-12 | Ensure services provided by the nursing facility meet professional standards of quality. | D | complaint | corrected 2026-03-31 |
| 2026-02-12 | Provide and implement an infection prevention and control program. | E | Health | corrected 2026-02-23 |
| 2026-02-12 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Health | corrected 2026-02-23 |
| 2026-02-12 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Health | corrected 2026-02-23 |
| 2026-02-12 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2026-02-23 |
| 2026-02-12 | 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 | Health | corrected 2026-02-23 |
| 2026-02-12 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Health | corrected 2026-02-23 |
| 2025-09-02 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | complaint | corrected 2025-09-03 |
| 2025-07-29 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | Past Non-Compliance |
| 2025-07-03 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2025-07-07 |
| 2025-05-09 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2025-05-09 |
| 2025-01-29 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2025-02-13 |
| 2024-10-10 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Health | corrected 2024-10-24 |
| 2024-10-10 | Reasonably accommodate the needs and preferences of each resident. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | 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. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide and implement an infection prevention and control program. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Health | corrected 2024-10-24 |
| 2024-10-10 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2024-10-24 |
| 2024-10-10 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2024-10-24 |
| 2024-10-10 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Health | corrected 2024-10-24 |
| 2024-10-10 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Health | corrected 2024-10-24 |
| 2024-06-20 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | complaint | corrected 2024-06-21 |
| 2024-06-20 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | E | complaint | corrected 2024-06-21 |
| 2024-06-20 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-06-21 |
| 2024-05-07 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2024-05-08 |
| 2024-05-07 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | complaint | corrected 2024-05-08 |
| 2024-04-23 | Ensure services provided by the nursing facility meet professional standards of quality. | D | complaint | corrected 2024-04-25 |
| 2024-02-13 | Ensure services provided by the nursing facility meet professional standards of quality. | D | complaint | corrected 2024-02-29 |
| 2024-02-07 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2024-02-29 |
| 2024-02-07 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2024-02-29 |
| 2023-12-22 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | complaint | corrected 2024-01-22 |
| 2023-12-22 | Ensure services provided by the nursing facility meet professional standards of quality. | D | complaint | corrected 2024-01-22 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| SWC CA OPCO 2 LLC | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 05/01/2022 |
| CHESLEY, AARON | 5% Or Greater Indirect Ownership Interest | Individual | 50% | since 05/01/2022 |
| CHESLEY, AARON | Corporate Officer | Individual | NOT APPLICABLE | since 05/01/2022 |
| GAMETT, JAMES | Corporate Officer | Individual | NOT APPLICABLE | since 05/01/2022 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 555861. Corrections: data@carerecords.org.