Blue Oak Post-Acute

Nursing Home · Santa Rosa, CA

CMS overall rating 2/5 Abuse citation For profit - Corporation

CMS certification number056090
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

850 Sonoma Ave
Santa Rosa, CA 95404
Sonoma County
Phone
(707) 544-7750
ZIP code
95404 – all care providers

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Facility details

Certified beds
181
Residents per day
163.3 (90% occupied)
Ownership
For profit - Corporation
Legal name
Hilborn Care, INC.
Medicare certified since
February 1, 1974
Participates in
Medicare and Medicaid
Council
Both council

CMS star ratings

Overall★★★★★ 2/5
State avg 3.2
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 5/5
State avg 3.3
Quality measures★★★★★ 3/5
State avg 4.1
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 2/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.44 (state 4.52 · U.S. 3.86)
Registered nurses (RN)
0.56 (state 0.67 · U.S. 0.69)
Licensed practical nurses
0.76 (state 1.20 · U.S. 0.86)
Nurse aides
2.13 (state 2.65 · U.S. 2.32)
Weekend total
3.05 (state 4.09 · U.S. 3.42)
Nursing staff turnover
18.5 (state 36.7 · U.S. 45.8)%
RN turnover
19.0 (state 38.1 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
November 25, 2025
Health deficiencies (last cycle)
27.0 (state 15.7 · U.S. 9.3)
From complaints
12
Citations on record (3 years)
60 health · 20 fire safety · includes actual harm
DateCitationSeverityStatus
2026-06-10 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Deficient, Provider has no plan of correction
2026-06-10 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Deficient, Provider has no plan of correction
2026-05-01 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-06-04
2026-04-16 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-17
2026-04-02 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-03
2026-04-02 Make sure that a working call system is available in each resident's bathroom and bathing area.
F0919 · Environmental Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-03
2026-01-07 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-01-08
2026-01-07 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-01-08
2025-12-22 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-01-06
2025-12-11 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-01-05
2025-12-11 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-01-05
2025-11-25 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F0806 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Make sure that a working call system is available in each resident's bathroom and bathing area.
F0919 · Environmental Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-11-25 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F0887 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-03
2025-09-08 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-09-22
2025-07-22 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-26
2025-07-22 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-26
2025-07-22 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-26
2025-05-08 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-05
2025-04-16 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-28
2025-01-07 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-01-23
2024-03-29 Assist a resident in gaining access to vision and hearing services.
F0685 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-24
2023-11-17 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F0557 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 The resident has the right to receive notices in a format and a language he or she understands.
F0574 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 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.
F0584 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Provide safe, appropriate pain management for a resident who requires such services.
F0697 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F0725 · Nursing and Physician Services Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Hire a qualified full-time social worker in a facility with more than 120 beds.
F0850 · Administration Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F0943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05
2023-11-17 Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-05

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

2 penalties in the last three years, including $36,892 in fines.

DateTypeAmount
2025-12-11Fine$28,614
2025-01-07Fine$8,278

Ownership & management

NameRoleSince
Jose, Josekutty (individual)Administrator · NOT APPLICABLE
Matalon, Eran (individual)Administrator · NOT APPLICABLE
Rose, Megan (individual)Administrator · NOT APPLICABLE
Suratos, Raul (individual)Administrator · NOT APPLICABLE
Trask, April (individual)Administrator · NOT APPLICABLE
Jose, Josekutty (individual)Corporate Director · NOT APPLICABLE
Jose, Josekutty (individual)Corporate Officer · NOT APPLICABLE
Jose, Josekutty (individual)Direct Ownership Interest · NOT APPLICABLE
Matalon, Eran (individual)Operational/managerial Control · NOT APPLICABLE
Rose, Megan (individual)Operational/managerial Control · NOT APPLICABLE
Suratos, Raul (individual)Operational/managerial Control · NOT APPLICABLE
Trask, April (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Blue Oak Post-Acute?

Blue Oak Post-Acute has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in California.

How many beds does Blue Oak Post-Acute have?

It has 181 certified beds and cares for about 163 residents per day.

Has Blue Oak Post-Acute been fined?

Yes. CMS lists 2 penalties totaling $36,892 in the last three years.

What is the phone number of Blue Oak Post-Acute?

(707) 544-7750. The facility is located at 850 Sonoma Ave, Santa Rosa, CA 95404.

Other nursing homes in Santa Rosa

Compare all nursing homes in Santa Rosa, CA →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.