The resident, identified in inspection records as Resident 1, told inspectors she worries about colder weather and rain. She confirmed she will need to relocate to a different parking lot because her current location is prone to flooding.
Federal investigators discovered the resident's last entry in the facility's leave of absence binder was September 24 at 10:30 a.m. When she returned to the facility at 4 p.m. that day, she expressed that she wanted to be permitted to return to the nursing home.
The facility has not allowed her back.
College Oak is disputing the immediate jeopardy citation, which indicates inspectors found conditions that could cause serious injury, harm, impairment or death to residents.
The case exposes a regulatory gap where nursing homes can maintain a resident's admission status while effectively barring them from the facility. Resident 1 remains officially admitted to College Oak despite living in her car for nearly two months.
Federal nursing home regulations require facilities to provide proper discharge procedures when residents leave permanently. The inspection revealed College Oak failed to follow its own policies for resident-initiated discharges or facility-initiated transfers.
According to the facility's October 2022 policy on discharging residents, when a resident wishes to be discharged to a setting that appears unsafe, the facility must discuss the implications and risks with the resident. Staff should document that other suitable options were presented and determine if a referral to Adult Protective Services is necessary.
No evidence exists that College Oak followed these procedures.
The facility's August 2006 policy requires a doctor's order for any resident leaving the premises, excluding transfers, discharges or medical appointments. Each resident must obtain physician approval for any leave of absence.
College Oak's March 2025 policy on transfer and discharge notices requires written notification to residents at least 30 days before any move. The notice must include the specific reason for transfer or discharge, the effective date, the location where the resident is being moved, and information about appeal rights.
The facility must also notify the State Long-Term Care Ombudsman of any discharge.
Inspection records contain no evidence these notifications occurred for Resident 1.
The facility's October 2022 policy defines therapeutic leave as a type of resident-initiated transfer. However, if the facility decides not to allow the resident to return, the transfer becomes a facility-initiated discharge requiring proper procedures.
College Oak appears to have converted Resident 1's temporary leave into a permanent exclusion without following discharge protocols.
For resident-initiated discharges, the facility's own policy requires documentation of the resident's intent to leave, a discharge care plan, and detailed discussions about post-discharge arrangements. The comprehensive care plan should contain the resident's goals for admission and desired outcomes aligned with the discharge.
None of these requirements appear to have been met.
The inspection occurred during a complaint investigation, indicating someone reported concerns about the facility's handling of Resident 1's situation to state regulators.
Immediate jeopardy citations represent the most serious level of deficiency federal inspectors can issue. They indicate conditions that pose immediate threat to resident health and safety requiring immediate correction.
The citation affects few residents, according to inspection records, but highlights broader questions about how nursing homes handle residents who want to leave but may lack safe housing options.
Federal regulations require nursing homes to ensure safe and orderly transfers and discharges. Facilities cannot simply exclude residents without following proper procedures designed to protect vulnerable adults.
College Oak's policies acknowledge the facility's responsibility when residents choose discharge locations that appear unsafe. The procedures require staff to discuss risks, present alternatives, and potentially contact Adult Protective Services.
Living in a car during Sacramento's winter months would clearly qualify as an unsafe discharge setting requiring these protections.
The facility's dispute of the citation suggests management disagrees with inspectors' findings about the severity of the situation or the facility's responsibility for Resident 1's circumstances.
Nursing homes sometimes argue that residents who leave voluntarily bear responsibility for their own housing arrangements. However, federal regulations place specific obligations on facilities to ensure proper discharge planning and safety assessments.
The case also raises questions about the facility's leave of absence procedures. Resident 1's September 24 entry in the LOA binder indicates she was following established protocols for temporary departures.
Her 4 p.m. return that day and expressed desire to be readmitted suggests the leave was intended as temporary. The facility's subsequent refusal to allow her return appears to have transformed a temporary absence into permanent homelessness.
College Oak's therapeutic leave policy specifically addresses this scenario, requiring the facility to treat denied returns as facility-initiated discharges subject to full regulatory protections.
The timing is particularly concerning as Sacramento enters its rainy season. Resident 1's expressed worry about colder weather and flooding reflects the immediate dangers of her situation.
Federal inspectors completed their investigation on November 20, nearly two months after Resident 1's last documented presence at the facility. The extended timeline suggests the situation persisted for weeks before regulatory intervention.
The inspection narrative ends abruptly, providing no information about immediate corrective actions or the resident's current status. College Oak's dispute of the citation means the case will likely proceed through federal appeals processes while Resident 1 remains in her car.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for College Oak Nursing & Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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