Chinese Hospital D/P SNF
845 Jackson Street, San Francisco, CA 94133 · Non profit - Corporation · 23 certified beds · (415) 677-2480 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | Not rated |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents who lose too much weight | 4.5% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 13.7% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents with pressure ulcers | 5.9% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.3% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 23 beds and averages 19.4 residents a day — about 84% occupied, or roughly 4 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.82 hrs/resident/day on weekends vs 5.50 on weekdays — 12% thinner on weekends. RN hours go from 1.76 to 1.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · E2026-02-26 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of six sampled residents (Residents 26, 14, and 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1. For Resident 26, there was no specific target behavior monitoring for the use of Lorazepam (medication used to treat anxiety) and2. For Residents 14 and 15, there was no diagnosis and/or specific condition for the use of antipsychotic medication.These deficient practices had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.1. Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-26 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop care plans for Residents 1, 14, 15, and 26, four residents out of a total sample of 8 residents. These were the areas the facility failed to care plan:Resident 15- antipsychotic medicationResident 1- anti-anxiety medication Resident 26- anti-anxiety medicationResident 14- bed railsThese failures had the potential to negatively impact these residents' health and safety.1. A concurrent interview and review of Resident 15's medical records was conducted on 2/24/26 at 1:59 PM with the Director of Staff Development (DSD). Review of Resident 15's medical records titled Order Summary Report, for February 2026, indicated Resident 15 had a physician order for .Paliperidone Palmitate. for schizoaffective (once a month injection to be administered at a clinic). Paliperidone palmitate is a medication used to treat the symptoms of mental disorders, including schizophrenia. Schizophrenia is a mental health condition presenting with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report three allegations of abuse within the mandated time frame to California Department of Public Health (CDPH), the Ombudsman (advocates for residents in nursing homes), and local law enforcement for one of one sampled resident (Resident 34). In addition, the facility failed to report the result of its investigation to CDPH within five working days.This failure to follow mandated reporting timeframes had the potential to delay investigation and implementation of protective measures for all residents of the facility.Review of three facility documents, titled Report of Suspected Dependent Adult/Elder Abuse (Reports 1, 2, and 3), dated 12/21/24 indicated on Report 1 and Report 2 that on 12/20/24 (time not specified), Resident 34 reported to Social Services Manager (SSM) that Registered Nurse (RN) 3 physically and verbally abused him by intimidating him, dragging him from bed, giving his medications late, shoving laxatives in his mouth, and along with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send notification to Ombudsman for one of two residents (Resident 24) when Resident 24 was discharged from the facility against medical advice (AMA).This failure had the potential for resident not having the right to appeal when necessary.Resident 24 was admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by underlying condition), anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body) and congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, causing fluid buildup, fatigue, and shortness of breath).Review of facility document titled, Notice of Transfer or Discharge, dated 12/16/25, indicated, Resident 24 was discharged AMA on 12/16/25. There was no documentation that notice of discharge was sent to Ombudsman.During a concurrent interview and record review on 2/25/26 at 2:01 PM with Social Worker (SW), Resident 24's Notice of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of external catheter for one of one sampled resident (Resident 26).These deficient practices had the potential for resident not to receive appropriate treatment and services.Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and malnutrition.During an observation on 2/23/26 at 10:56 AM, Resident 26 was asleep in bed, with a catheter (a flexible tube used to deliver fluids into or withdraw fluids from the body) draining with yellowish urine to a drainage bag.During a concurrent interview and record review on 2/26/26 at 9:58 AM, with Licensed Vocational Nurse (LVN) 1, Resident 26's orders and care plans were reviewed. LVN 1 said Resident 26 had the catheter the on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order for oral suctioning for one of one sampled resident (Resident 14).This failure had the potential for Resident 14 not to receive appropriate treatment and services.Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred).During an observation on 2/23/26 at 10:22 AM, Resident 14 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister contained light yellowish secretions.During an interview on 2/25/26 at 10:44 AM, Hospital Aide (HA) 1 said that the oral suctioning equipment was used to suction secretions of Resident 14. HA 1 stated, I do the suctioning when needed.Review of Resident 14's care plan indicated, .Focus: Resident 14 has altered respiratory status and difficulty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review facility staff failed to accurately measure a controlled drug to enable exact reconciliations. Certain medications/chemical substances are subject to strict government control/oversight due to their potential for misuse and harm. For example: Morphine to treat moderate to severe pain.Staff failed to accurately measure the amount of Morphine within a bottle upon receipt and during shift-to-shift verification. This failure had the potential for drug diversion and medication error. Findings: During a concurrent observation, interview, and record review with Registered Nurse (RN 1) on 2/23/26 at 11:03 AM, a bottle of morphine was in the locked controlled substance cabinet of medication cart 3. Observation of the amount of morphine within the bottle indicated it was above the 30 ml (millimeter = a unit of liquid measurement) mark. This observation was confirmed with RN 1 and she agreed there was more than 30 ml of morphine inside the bottle. However, review of a facility document titled Controlled Drug Record, dated 11/20/2025, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review facility staff failed to ensure a pharmacy printed label for a medication was legible. This failure had the potential for medication error. Findings: During a concurrent observation and interview on 2/23/26 at 11:19 AM with Registered Nurse (RN 1), the following was observed in medication cart 2. There was a bottle of nystatin powder (used to treat skin fungal and/or rashes) with an illegible pharmacy printed label. RN1 inspected the label, agreed the label exhibited water damage/ spreading of the ink and confirmed she could not read the resident's name on the label. RN1 stated staff should have called pharmacy and requested a new label for the nystatin powder. During an interview on 2/24/26 at 11:02 AM the Associate Director, Integrated Pharmacy Services (ADIPS) stated she expected staff to call pharmacy to print out a new label if a label becomes illegible. The ADIPS stated as a result of the above findings, staff did an audit and found and replaced another illegible medication label. Review of the facility's policy titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 14) when the Yankauer suction tip (a bulb-tipped instrument used to remove saliva, blood, and mucus from the oral cavity to maintain a clear airway and prevent aspiration) was not covered while not in use.This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 14.Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred).During an observation on 2/23/26 at 10:22 AM, Resident 14 was asleep in bed, oral suctioning equipment was at resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-09 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility document review, the facility failed to have a system in place to ensure the safe storage of residents' personal perishable food. This failure had the potential to result in foodborne illness for 18 residents who took food by mouth out of a facility census of 19. Findings: Review of the Policy and Procedure (P&P) titled Bringing In Outside Food for Residents in Skilled Nursing Unit revised January 2024, showed Resident's nurse will store the perishable food in the resident refrigerator and freezer located in Dining Room on the SNF (Skilled Nursing Facility). The temperature will be systematically monitored, and a temperature log will be maintained in collaboration with the Facilities department. Review of the P&P titled Food Handling revised March 2024, showed temperatures of refrigerators and freezers will be monitored daily and documented. Refrigerators should be below 40 degrees Fahrenheit (F) and freezers at or below 0 degrees F. An observation on 8/5/24 at 12:10 p.m., showed a compact refrigerator and a compact freezer located in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · Ecited before2024-08-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of female external catheter for two of two sampled residents (Residents 158 and 201). This failure had the potential for residents to not receive appropriate treatment and services. Findings: 1. Resident 158 was admitted on [DATE] with diagnoses including obesity, chronic pain, adult failure to thrive (inability to sustain weight due to poor nutrition), and major depressive disorder. During an observation on 8/5/24 at 10:39 AM, Resident 158 was asleep in bed, with a catheter (a flexible tube used to deliver fluids into or withdraw fluids from the body) draining with yellowish urine to a canister and attached to a wall-mounted suction machine. During an interview on 8/5/24 at 12:38 PM, Resident 158 acknowledged the use of a catheter and stated, The catheter drains my urine. During a concurrent interview and record review on 8/7/24 at 10:15 AM, with Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident was admitted on [DATE], with diagnoses including encephalopathy (a disturbance in the brain function causing confusion, memory loss), and dysphagia. During an observation on 8/5/24 at 11:00 AM, Resident 205, was in bed, had a tubing attached to a suction catheter, and a canister filled with whitish fluid connected to the suction machine. During an interview on 8/5/24 at 11:15 AM, with LVN 1, LVN 1 confirmed Resident 205 required suctioning on as needed (PRN) basis and stated, I did not suction him yet on my shift. During an interview on 8/7/24 at 10:20 AM, with RN 2, per RN2 suctioning is on PRN basis, the canister and suction tip should be changed every 2-3 days, will check the policy, date is important to know when to change the set. Review of Resident 205's clinical records, the OSR, there was no MD order for suctioning. Review of Resident 205's care plans indicated no care plan for suctioning of oral secretions. During a concurrent interview and record review on 8/7/24 at 2:00 PM, with RN 1,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-09 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assessed for risk of entrapment, risk and benefits for the use of bed rails were reviewed and bed rail assessment reflect the use of bed rails for three of eight sampled residents (Residents 151, 159, and 207). These deficient practices had the potential to put the residents at risk for entrapment, accidents, or injuries due to the use of bed rails. Findings: 1. Resident 151 was admitted on [DATE] with diagnoses including transient ischemic attack (TIA-a brief episode when blood flow to the brain is temporarily cut off), prostate cancer, and depression. Mental status assessment indicated Resident 151 was moderately impaired. During an observation on 8/5/24 at 9:58 AM, Resident 151 was asleep in bed, with both upper bed rails up. During a subsequent observation on 8/7/24 at 9:54 AM, Resident 151 was asleep in bed, with both upper bed rails up. On concurrent interview with Hospital Aide (HA) 1, HA 1 said that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-09 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not send a copy of the reason for discharge to the office of the local Ombudsman, when one of two residents (Resident 2) was discharged to a lower level of care (board and care home). Findings: Review of Physician Discharge summary, dated [DATE], indicated, .Resident 2 was admitted [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), obesity, was involved in minor MVA (Motor Vehicle Accident) . Patient completed therapy .patient is stable to discharge with home care . During an interview on 8/8/24 at 11:35 AM, with Social Work Manager (SWM), SWM, when patient was admitted , APS (Adult protective Services) was already on the case. Patient was referred to (IOA) Institute on Aging, who helped SW apply for assisted living waiver, so she can go to a board and care. The board and care were able to accept her as Hoyer-lift and ADLs (Activities of daily living) assisted patient. Referred patient to Upward Health for case management if she will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) that included measurable objectives and specific interventions for one of eight sampled residents (Residents 159) when there was no individualized person-centered CP for the use of Venlafaxine (medication used to treat depression) for Resident 159. This failure had the potential for not meeting the resident's nursing needs and goals to attain their highest practicable well-being. Findings: Resident 159 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), cocaine abuse, and depression. Review of Resident 159's Order Summary Report, active orders as of 8/8/24, indicated, Resident 159 had an order of Venlafaxine with a start date of 7/19/24. During a concurrent interview and record review on 8/7/24 at 10:39 AM, with Registered Nurse (RN) 3, Resident 159's care plans were reviewed. RN 3 confirmed that Resident 159 had an order for Venlafaxine with a start date of 7/19/24. RN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-09 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interviews and record review, the facility did not provide daily, the nurse staffing information, when on 8/5/24, 8/6/24, and 8/7/24, there was no staffing data information posted. Findings: During an interview on 8/5/24 at 10:22 AM, with Interim Director of Nursing (IDON), per IDON, the staffing information should be posted. Facility provided daily nursing assignments and monthly staff schedule. Not the staffing data required. On 8/7/24, asking the IDON for the staffing posting, the Census and Direct Care service Hours Per Patient Day (DHPPD) was posted in the nursing station. Review of facility policy and procedure titled, Posted Nurse Staffing Information, dated 4/20/23, indicated, .It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time .1. The facility will post the following on a daily basis . 2. The facility will post the nurse staffing data daily at the beginning of each shift.
- Potential for harm · D2024-08-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 158 and 159) were free from unnecessary psychotropic medication (drug that affect brain activities associated with mental processes and behavior) when there was no specific target behavior monitoring for the use of Venlafaxine (medication used to treat depression). This failure had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the residents' mental, physical, and psychosocial well-being. Findings: 1. Resident 158 was admitted on [DATE] with diagnoses including obesity, chronic pain, adult failure to thrive (inability to sustain weight due to poor nutrition), and major depressive disorder. During a review of Resident 158's clinical record, the Order Summary Report (OSR), active orders as of 8/8/24, indicated, .Venlafaxine HCl ER Oral Tablet Extended Release 24-hour 75 milligram (mg)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe medication storage practice in one of three medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when several prescription medications were kept on top of a med cart and available for taking. This failed practice could contribute to unsafe medication storage and the potential for drug diversion. Findings: During a concurrent observation and interview on 8/6/24 at 8:33 AM, with Interim Director of Nursing (IDON), a medication cart was found on the hallway outside of a Resident's room (room [ROOM NUMBER]). On top of the med cart were bottles of prescription medications (metoprolol 50 mg - medication for treatment of high blood pressure, oxcarbazepine 300 mg - a medication used in the treatment of partial seizures, lisinopril 40 mg - medication for treatment of high blood pressure, and tamsulosin 0.4 mg - medication used in reducing the symptoms of an enlarged prostate gland) belonging to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 151) when the tip of the oral suction (involves inserting a small plastic tube attached to a suction machine into the mouth to remove saliva or mucus) tubing was touching the floor. This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 151. Findings: Resident 151 was admitted on [DATE] with diagnoses including transient ischemic attack (TIA-a brief episode when blood flow to the brain is temporarily cut off), dysphagia (difficulty swallowing), and depression. Mental status assessment indicated Resident 151 was moderately impaired. During an observation on 8/5/24 at 9:58 AM, Resident 151 was asleep in bed, oral suctioning equipment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CHEN, DI AN | Individual | CORPORATE DIRECTOR | since 01/28/2021 |
| CHOW, CHARLES | Individual | CORPORATE DIRECTOR | since 01/28/2021 |
| ENG, ROGER | Individual | CORPORATE DIRECTOR | since 01/28/2021 |
| LEE, DING BONG | Individual | CORPORATE DIRECTOR | since 01/28/2021 |
| LEUNG, CLIFTON | Individual | CORPORATE DIRECTOR | since 01/28/2020 |
| LOUIE, HARVEY | Individual | CORPORATE DIRECTOR | since 01/25/2005 |
| LUK, CHIU KI | Individual | CORPORATE DIRECTOR | since 01/24/2025 |
| LUU, DONALD | Individual | CORPORATE DIRECTOR | since 01/28/2021 |
| NG, THOMAS | Individual | CORPORATE DIRECTOR | since 01/19/1982 |
| SIT, JACK | Individual | CORPORATE DIRECTOR | since 01/28/2020 |
| TAM, YICK | Individual | CORPORATE DIRECTOR | since 01/24/2025 |
| TANG, SHERMAN SHICK-JUE | Individual | CORPORATE DIRECTOR | since 01/24/2025 |
| TSUKERMAN, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/30/2023 |
| WONG, LAWRENCE | Individual | CORPORATE DIRECTOR | since 06/29/2021 |
| YEE, LAWRENCE | Individual | CORPORATE DIRECTOR | since 01/24/2025 |
| YUEN, THOMAS | Individual | CORPORATE DIRECTOR | since 01/30/2023 |
| CHUNG, CHI-KUO | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| ZHANG, JIANQING | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
CMS files one row per role, so the 22 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555933. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.