nursing home in Tulare, CA

Grand Oaks Care

897 North M Street, Tulare, CA 93274 · (559) 687-1340

★★★★★3
Average
CMS overall star rating
  • Health inspections★★★★★3
  • Staffing★★★★★2
  • Quality measures★★★★★4

Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data

Grand Oaks Care at a glance

Grand Oaks Care is a 99-bed for-profit nursing home in Tulare, California (Tulare County).

CMS gives it 3 out of 5 stars on its overall star rating, close to the California average of 3.2.

Residents receive about 4.2 hours of nursing care per day (0.3 of them from registered nurses), worse than the state average of 4.5 hours.

Its most recent standard health inspection (February 12, 2026) found 8 health citations. The California average is 15.5.

It has not received a federal fine in the past three years.

Nursing staff turnover is 50.4% per year (state average 36.7%).

Facility details

Type
Nursing home
Ownership
For Profit - Limited Liability Company
Beds
99
Certified for
Medicare and Medicaid
Chain / affiliated entity
Ajc Healthcare
Medicare-certified since
June 26, 2009
Resident/family council
Resident
County
Tulare County
CMS Certification Number
555861

Ratings

MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Overall star rating ⓘ (higher is better)3 / 53.2 / 53 / 5Average
Health inspection rating ⓘ (higher is better)3 / 52.8 / 52.8 / 5Average
Staffing rating ⓘ (higher is better)2 / 53.3 / 52.9 / 5Worse
Quality measures rating ⓘ (higher is better)4 / 54.1 / 53.6 / 5Average
Long-stay quality rating (higher is better)5 / 54.4 / 53.8 / 5Better
Short-stay (rehab) quality rating (higher is better)3 / 53.6 / 53.3 / 5Average

Staffing

This facility4.25 hrsCalifornia average4.52 hrsU.S. average3.86 hrs
Total nurse staff hours per resident per day: this facility vs. California and U.S. averages
MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Total nurse staff hours per resident per day ⓘ (higher is better)4.25 hrs4.52 hrs3.86 hrsBetter
Registered nurse hours per resident per day (higher is better)0.34 hrs0.67 hrs0.69 hrsWorse
Nurse aide hours per resident per day (higher is better)2.77 hrs2.65 hrs2.32 hrsBetter
Weekend nurse staff hours per resident per day (higher is better)3.81 hrs4.09 hrs3.42 hrsBetter
Nursing staff turnover (yearly) (lower is better)50.4%36.7%45.8%Worse
Registered nurse turnover (yearly) (lower is better)25%38.1%42.9%Better
Administrators who left in the past year (lower is better)001Better

Inspections

This facility8California average16U.S. average9
Health citations in the most recent inspection: this facility vs. California and U.S. averages
MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Health citations in the most recent inspection (lower is better)8169Better
Citations from complaint investigations (latest cycle) (lower is better)243Better
Weighted health inspection score ⓘ (lower is better)87105.880.6Worse

Penalties

This facility0California average1U.S. average1
Fines in the past 3 years: this facility vs. California and U.S. averages
MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Fines in the past 3 years (lower is better)011Better
Total fines in the past 3 years (lower is better)$0$23,986$30,972Better
All federal penalties in the past 3 years (lower is better)011Better

Size

MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Certified beds9999107
Average residents per day938886
Occupancy94.1%88.4%80.9%

Long-stay residents

This facility1.8%California average1.6%U.S. average3.2%
Long-stay residents with a fall causing major injury: this facility vs. California and U.S. averages
MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Long-stay residents with a fall causing major injury (lower is better)1.8%1.6%3.2%Better
Long-stay residents with pressure ulcers (lower is better)0.4%4.3%4.6%Better
Long-stay residents given antipsychotic medication (lower is better)3.3%12%15.4%Better
Long-stay residents with a urinary tract infection (lower is better)0%1.2%1.6%Better
Long-stay residents with a catheter left in the bladder (lower is better)0%0.8%0.8%Better
Long-stay residents needing more help with daily activities (lower is better)8.7%10.2%13.9%Better
Long-stay residents whose walking worsened (lower is better)20.7%9.8%14.1%Worse
Long-stay residents who lose too much weight (lower is better)5.8%4%5.2%Worse
Long-stay residents with depressive symptoms (lower is better)6.8%7.3%12.8%Better
Long-stay residents who were physically restrained (lower is better)0%0.4%0.1%Better
Long-stay residents given anti-anxiety or sleep medication (lower is better)20.4%13.7%19.5%Average
Long-stay residents with new or worse incontinence (lower is better)16.9%10.2%19%Better
Long-stay residents given a flu vaccine (higher is better)100%98.2%95.5%Average
Long-stay residents given a pneumonia vaccine (higher is better)100%98.6%93.6%Better

Short-stay residents

This facility0.9%California average1.5%U.S. average1.6%
Short-stay residents newly given antipsychotic medication: this facility vs. California and U.S. averages
MeasureThis facilityCalifornia avg.U.S. avg.vs. U.S.
Short-stay residents newly given antipsychotic medication (lower is better)0.9%1.5%1.6%Better
Short-stay residents given a flu vaccine (higher is better)100%93.2%79.8%Better
Short-stay residents given a pneumonia vaccine (higher is better)100%94.4%82%Better

Inspection citations

State inspectors cited this home for 55 health deficiencies and 17 fire safety deficiencies in the inspection records CMS currently publishes. None were rated as causing actual harm to residents.

DateCitationSeverityStatus
March 12, 2026
Complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
D
Potential harm, isolated
Corrected March 31, 2026
February 12, 2026
Fire safety
Provide a written emergency evacuation plan.
Miscellaneous Deficiencies · Tag K0711
F
Potential harm, widespread
Corrected February 27, 2026
February 12, 2026
Fire safety
Ensure proper usage of power strips and extension cords.
Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920
E
Potential harm, pattern
Corrected February 27, 2026
February 12, 2026
Fire safety
Have properly located and lighted "Exit" signs.
Egress Deficiencies · Tag K0293
D
Potential harm, isolated
Corrected February 23, 2026
February 12, 2026
Fire safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Miscellaneous Deficiencies · Tag K0741
D
Potential harm, isolated
Corrected February 27, 2026
February 12, 2026
Fire safety
Provide primary/alternate means for communication.
Emergency Preparedness Deficiencies · Tag E0032
C
No harm, widespread
Corrected February 23, 2026
February 12, 2026
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected February 23, 2026
February 12, 2026
Standard
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F0698
D
Potential harm, isolated
Corrected February 23, 2026
February 12, 2026
Standard
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
D
Potential harm, isolated
Corrected February 23, 2026
February 12, 2026
Standard
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F0656
D
Potential harm, isolated
Corrected February 23, 2026
February 12, 2026
Standard
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Tag F0812
D
Potential harm, isolated
Corrected February 23, 2026
February 12, 2026
Standard
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.
Pharmacy Service Deficiencies · Tag F0761
D
Potential harm, isolated
Corrected February 23, 2026
September 2, 2025
Complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Tag F0725
F
Potential harm, widespread
Corrected September 3, 2025
July 29, 2025
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Past Non-Compliance
July 3, 2025
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected July 7, 2025
May 9, 2025
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected May 9, 2025
January 29, 2025
Complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F0656
D
Potential harm, isolated
Corrected February 13, 2025
October 10, 2024
Fire safety
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies · Tag K0712
E
Potential harm, pattern
Corrected October 31, 2024
October 10, 2024
Fire safety
Provide properly protected cooking facilities.
Smoke Deficiencies · Tag K0324
D
Potential harm, isolated
Corrected October 31, 2024
October 10, 2024
Fire safety
Use approved construction type or materials.
Construction Deficiencies · Tag K0161
D
Potential harm, isolated
Corrected October 31, 2024
October 10, 2024
Fire safety
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies · Tag K0353
D
Potential harm, isolated
Corrected October 31, 2024
October 10, 2024
Fire safety
Install corridor and hallway doors that block smoke.
Smoke Deficiencies · Tag K0363
D
Potential harm, isolated
Corrected October 31, 2024
October 10, 2024
Fire safety
Have properly installed electrical wiring and gas equipment.
Services Deficiencies · Tag K0511
D
Potential harm, isolated
Corrected October 31, 2024
October 10, 2024
Fire safety
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918
C
No harm, widespread
Corrected October 31, 2024
October 10, 2024
Fire safety
Conduct testing and exercise requirements.
Emergency Preparedness Deficiencies · Tag E0039
C
No harm, widespread
Corrected October 31, 2024
October 10, 2024
Standard
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Tag F0867
F
Potential harm, widespread
Corrected October 24, 2024
October 10, 2024
Standard
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · Tag F0921
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
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.
Pharmacy Service Deficiencies · Tag F0761
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Tag F0756
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · Tag F0745
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
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.
Nursing and Physician Services Deficiencies · Tag F0726
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
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.
Quality of Life and Care Deficiencies · Tag F0688
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · Tag F0558
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
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.
Resident Rights Deficiencies · Tag F0578
E
Potential harm, pattern
Corrected October 24, 2024
October 10, 2024
Standard
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F0686
D
Potential harm, isolated
Corrected October 24, 2024
October 10, 2024
Standard
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · Tag F0806
D
Potential harm, isolated
Corrected October 24, 2024
October 10, 2024
Standard
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · Tag F0805
D
Potential harm, isolated
Corrected October 24, 2024
October 10, 2024
Standard
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected October 24, 2024
October 10, 2024
Standard
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · Tag F0623
D
Potential harm, isolated
Corrected October 24, 2024
October 10, 2024
Standard
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.
Resident Rights Deficiencies · Tag F0584
D
Potential harm, isolated
Corrected October 24, 2024
June 20, 2024
Complaint
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.
Administration Deficiencies · Tag F0837
E
Potential harm, pattern
Corrected June 21, 2024
June 20, 2024
Complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · Tag F0804
E
Potential harm, pattern
Corrected June 21, 2024
June 20, 2024
Complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609
D
Potential harm, isolated
Corrected June 21, 2024
May 7, 2024
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected May 8, 2024
May 7, 2024
Complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · Tag F0919
D
Potential harm, isolated
Corrected May 8, 2024
April 23, 2024
Complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
D
Potential harm, isolated
Corrected April 25, 2024
February 13, 2024
Complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
D
Potential harm, isolated
Corrected February 29, 2024
February 7, 2024
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected February 29, 2024
February 7, 2024
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected February 29, 2024
December 22, 2023
Complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Tag F0658
D
Potential harm, isolated
Corrected January 22, 2024
December 22, 2023
Complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · Tag F0655
D
Potential harm, isolated
Corrected January 22, 2024
November 2, 2023
Complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F0698
E
Potential harm, pattern
Corrected December 28, 2023
November 2, 2023
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected December 28, 2023
October 10, 2023
Complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F0689
D
Potential harm, isolated
Corrected October 30, 2023
October 13, 2022
Fire safety
Properly provide smoke detection systems in areas open to corridors.
Smoke Deficiencies · Tag K0347
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Fire safety
Have proper medical gas storage and administration areas.
Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Fire safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Miscellaneous Deficiencies · Tag K0741
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Fire safety
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies · Tag K0353
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Standard
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Tag F0812
F
Potential harm, widespread
Corrected November 17, 2022
October 13, 2022
Standard
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F0698
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · Tag F0679
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · Tag F0804
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · Tag F0676
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected November 17, 2022
October 13, 2022
Standard
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F0656
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Standard
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.
Resident Rights Deficiencies · Tag F0578
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Standard
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · Tag F0806
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Standard
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F0677
D
Potential harm, isolated
Corrected November 17, 2022
October 13, 2022
Standard
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.
Quality of Life and Care Deficiencies · Tag F0688
D
Potential harm, isolated
Corrected November 17, 2022

Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.

Fines and payment denials

CMS reports no federal fines or payment denials in the past three years.

Owners and managers

Individuals and organizations reported to CMS as owning or operating this nursing home.

NameRoleShareSince
SWC CA OPCO 2 LLC
Organization
5% or greater direct ownership interest100%05/01/2022
CHESLEY, AARON
Individual
5% or greater indirect ownership interest50%05/01/2022
CHESLEY, AARON
Individual
corporate officerNOT APPLICABLE05/01/2022
GAMETT, JAMES
Individual
corporate officerNOT APPLICABLE05/01/2022
LAWRENCE, MICHELLE
Individual
w-2 managing employeeNOT APPLICABLE05/01/2022

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Frequently asked questions

What is Grand Oaks Care's rating?

Grand Oaks Care has 3 out of 5 stars on the CMS overall star rating. The average for California nursing homes is 3.2 stars.

How many inspection citations did Grand Oaks Care receive?

Its most recent standard health inspection found 8 citations, compared with a California average of 15.5. Every citation is listed on this page with its severity.

Does Grand Oaks Care accept Medicare and Medicaid?

CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.

Who owns Grand Oaks Care?

It is for profit - limited liability company and part of Ajc Healthcare. The ownership section on this page lists the owners and managers reported to CMS.

Where is Grand Oaks Care and how do I contact it?

Grand Oaks Care is at 897 North M Street, Tulare, CA 93274. Phone: (559) 687-1340.

About this data

Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.