San Rafael Healthcare & Wellness Center, LP
1601 5th Avenue · San Rafael, CA · 94901 · 4154567170
54 certified beds For profit - Limited Liability company Chain: Corporate Interface Services
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $8,278 |
Inspection citations (53 in the current record)
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Potential for harm · D December 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 2, 2026 · Quality of Life and Care
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Potential for harm · D July 18, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 3, 2025 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected July 1, 2025 · Resident Rights
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Potential for harm · D June 3, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 3, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 1, 2025 · Infection Control
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Potential for harm · D May 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 23, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected May 13, 2025 · Quality of Life and Care
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Potential for harm · E April 23, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected May 13, 2025 · Environmental
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Potential for harm · E April 10, 2025 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected May 1, 2025 · Resident Rights
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Actual harm · G March 27, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 29, 2025 · Quality of Life and Care
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Potential for harm · D March 24, 2025 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected April 16, 2025 · Resident Rights
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Potential for harm · D March 24, 2025 · found via complaint
Implement 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.
Corrected April 16, 2025 · Pharmacy Service
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Potential for harm · D March 20, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected April 17, 2025 · Resident Rights
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Potential for harm · D March 20, 2025
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected April 17, 2025 · Resident Rights
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Potential for harm · D March 20, 2025
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.
Corrected April 17, 2025 · Resident Rights
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Potential for harm · D March 20, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected April 17, 2025 · Resident Rights
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Potential for harm · D March 20, 2025
Ensure each resident receives an accurate assessment.
Corrected April 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · E March 20, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 17, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 17, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected April 17, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected April 17, 2025 · Nursing and Physician Services
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Potential for harm · D March 20, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected April 17, 2025 · Pharmacy Service
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Potential for harm · E March 20, 2025
Ensure that residents are free from significant medication errors.
Corrected April 17, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 20, 2025 | Fine | $8,278 |
| March 20, 2025 | Payment Denial | 6 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055331 · certified since March 29, 1974. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.