Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
OAK GLEN POST ACUTE
CHERRY VALLEY, CA · 59 certified beds · Last Life Safety survey May 22, 2025
CMS Certification Number 555492 · first certified November 1991
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed June 15, 2023 (change of ownership)from DAVID KLEIS III LLC
Position within CA
23 citations — more than 63% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: May 2026 to November 2026. This facility’s last Life Safety survey was May 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
11 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 10, 2022 | 7 |
| April 12, 2024 | 11 |
| May 22, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | 3 | 2025-05-22 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-05-22 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-05-22 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-05-22 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2024-04-12 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2022-11-10 |
| E-0031 | Provide emergency officials' contact information. | 1 | 2024-04-12 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-04-12 |
What the citations cover
- Emergency Preparedness Deficiencies 11
- Smoke Deficiencies 6
- Miscellaneous Deficiencies 2
- Services Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 11 |
| Smoke Deficiencies | 6 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 22, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 15, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 1, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 11, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 1, 2025) |
April 12, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (June 10, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 10, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 10, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 10, 2024) |
November 10, 2022 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 30, 2022) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (November 30, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 30, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 30, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 30, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 30, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.