Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Sherwood Oaks Post Acute

Thousand Oaks, CA · 99 certified beds · Last Life Safety survey May 21, 2026

CMS Certification Number 555794 · first certified July 2002

Ownership

Operated by PACS GROUP · For profit - Corporation

Ownership changed August 1, 2021 (change of ownership)from WINDSOR WESTLAKE HEALTHCARE LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CA

42 citations — more than 97% 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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 11 citations; the earlier surveys in the window averaged 10.3. With 4 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was May 2026. 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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5 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

12 of the 42 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)

4 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 42 Life Safety citations above. The Physical Environment Index

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

Citations on file over three years

Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	42
Median facility in CA	19
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 17, 2022	17
February 6, 2025	13
March 3, 2025	1
May 21, 2026	11

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2026-05-21
K-0363	Install corridor and hallway doors that block smoke.	3	2026-05-21
K-0531	Have elevators that firefighters can control in the event of a fire.	2	2025-03-03
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2026-05-21
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2025-02-06
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-02-06
K-0920	Ensure proper usage of power strips and extension cords.	2	2026-05-21
E-0032	Provide primary/alternate means for communication.	2	2026-05-21

What the citations cover

Citations by CMS category

Smoke Deficiencies 13
Emergency Preparedness Deficiencies 12
Gas, Vacuum, and Electrical Systems Deficiencies 7
Miscellaneous Deficiencies 4
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	13
Emergency Preparedness Deficiencies	12
Gas, Vacuum, and Electrical Systems Deficiencies	7
Miscellaneous Deficiencies	4
Services Deficiencies	3
Egress Deficiencies	2
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 21, 2026 — 11 citations

Citations issued on May 21, 2026
Tag	What the surveyor checks	Status
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (June 25, 2026)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (June 25, 2026)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (June 29, 2026)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (June 25, 2026)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (June 25, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (June 29, 2026)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (June 25, 2026)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (June 25, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (June 25, 2026)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (June 25, 2026)
K-0929	Ensure precautions for handling oxygen cylinders and equipment are correctly followed.	Deficient, Provider has date of correction (June 25, 2026)

March 3, 2025 — 1 citation

Citations issued on March 3, 2025
Tag	What the surveyor checks	Status
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (March 13, 2025)

February 6, 2025 — 13 citations

Citations issued on February 6, 2025
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (March 13, 2025)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (March 13, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 13, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 19, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 19, 2025)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (March 13, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 27, 2025)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (March 13, 2025)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (March 13, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 13, 2025)
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 (February 28, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (March 26, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 24, 2025)

November 17, 2022 — 17 citations

Citations issued on November 17, 2022
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (December 27, 2022)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (December 27, 2022)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (December 27, 2022)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (December 27, 2022)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (December 27, 2022)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (December 27, 2022)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (December 27, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (December 27, 2022)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (December 27, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 27, 2022)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (December 27, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 27, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (December 27, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 27, 2022)
K-0700	Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.	Deficient, Provider has date of correction (December 27, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 27, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (December 27, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.