Home / California / San Francisco
601 Duboce Ave, San Francisco, CA 94117 · San Francisco County · (415) 600-6000
38 certified beds, about 27 residents a day · Non profit - Corporation · Medicare and Medicaid since 1970
CMS Care Compare ratings, data as of September 1, 2026 · CCN 056245 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 9, 2026, inspectors cited 4 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 10 health citations since April 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 8.97 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 6.62 of those hours.
29.0% of nursing staff left within the year CMS measured (California average 36.7%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 10 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of three residents (Residents 10 and 30) were limited to 14 days and/or attending physician or prescribing practitioner documentation to support medication order extension. This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.
Inspectors wroteBased on interview and record review, the facility failed to monitor weights according to physician orders for two (Resident 14 and Resident 16) out of 12 sampled residents. This failure may limit and/or negatively impact clinicians' treatment decisions due to unavailable information.
Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 14 (one out of 12 sample residents) was free from unnecessary medication when Remeron (a medication that treats depression and other conditions by adjusting brain chemistry to improve mood, energy, and feelings of well-being, helping to regulate mood, sleep, and appetite ) was prescribed with no identified target behaviors and no diagnosis related to depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting daily life, affecting how you feel, think, and handle activities like sleeping, eating, or working). This failure may result in the use of Remeron as an unnecessary medication.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner when:1. A container of soup and an opened bag of meatballs were not dated.2. Food debris, an avocado, a packet of parsley, and a packet of cilantro were found on the floor of the walk-in refrigerator and freezer. Failure to store food in a sanitary manner had the potential to subject residents to contaminated food and/or foodborne illnesses.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of 12 sampled residents' (Resident 11 and 22) dignity were protected when their urinary bags were clearly visible from the hallway and were not contained in urinary bags. This failure may cause feelings of embarrassment to both Residents 11 and 22.
Inspectors wroteBased on interview, and record review, the facility failed to send a copy of the written notice to a representative of the Office of the State Long-Term Care Ombudsman after the facility-initiated discharge for Resident 20. This failure had the potential not to provide added protection to residents from being inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Ombudsman is aware of facility practices and activities related to transfers and discharges.
Inspectors wroteBased on interview and record review, the facility failed to measure pressure injuries for 1 of 12 sampled residents (Resident 8) upon admission and on a regular basis. This failure to measure Resident 8's pressure injuries on his left and right heels upon admission and on a regular basis did not ensure the facility was objectively monitoring these pressure injuries over time (102 days).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when nine expired nutrition supplements were found in the kitchen storage room. This failure had the potential to put residents at risk for foodborne illnesses.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container had a lid and refuse were disposed in a proper manner. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility.
Inspectors wroteBased on observation, interview and record review, a nurse failed to follow facility policy regarding disinfecting a shared device after medication administration. Failure to disinfect a shared device did not ensure other residents were protected from infection.
13 fire safety citations on file: 7 on January 9, 2026, 3 on July 11, 2024, 3 on April 28, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 8.97 | 4.52 | 3.86 |
| Registered nurses | 6.62 | 0.67 | 0.69 |
| All nursing staff on weekends | 8.55 | 4.09 | 3.42 |
| Nurse aides | 2.34 | ||
| Licensed practical nurses | 0.00 | ||
| Nursing staff turnover (share who left in a year) | 29.0% | 36.7% | 45.8% |
| Registered nurse turnover | 27.5% | 38.1% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 9.13 on weekdays and 8.55 on weekends, 6% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.45 in April to June 2025 to 8.97 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 8.97 | 6.62 | 9.13 | 8.55 | 0.6% | 0 of 90 | 27 |
| Oct to Dec 2025 | 9.32 | 6.88 | 9.41 | 9.07 | 0.6% | 0 of 92 | 23 |
| Jul to Sep 2025 | 9.18 | 6.66 | 9.42 | 8.58 | 0.2% | 0 of 92 | 25 |
| Apr to Jun 2025 | 6.45 | 4.74 | 6.62 | 5.99 | 1.5% | 0 of 91 | 26 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.1 | 1.4 | 1.6 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.2 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.2 | 11.2 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for California Pacific Medical Ctr- Davies Campus Hosp's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (79.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
79.8% this home
Better than the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 133 eligible stays.
10.3% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 131 eligible stays.
5.7% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 97 eligible stays.
39.7% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 141 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 165 residents counted.
2.2% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 165 residents counted.
97.5% this home
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 119 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SUTTER BAY HOSPITALS.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sutter Bay Hospitals | 5% or greater direct ownership interest | Organization | 100% | 02/01/2016 |
| Sutter Health | 5% or greater indirect ownership interest | Organization | 100% | 07/31/2009 |
| Gates, John | W-2 managing employee | Individual | 01/01/2010 | |
| Petrini, Julie | W-2 managing employee | Individual | 01/01/2019 | |
| Bell, Diana | Corporate director | Individual | 05/20/2015 | |
| Black, David | Corporate director | Individual | 05/20/2015 | |
| Conforti, James | Corporate director | Individual | 03/12/2012 | |
| Deikel, Theodore | Corporate director | Individual | 01/01/2010 | |
| Eisenhardt, Emil | Corporate director | Individual | 08/05/2009 | |
| Flowers, Eric | Corporate director | Individual | 05/20/2015 | |
| Hill, Richard | Corporate director | Individual | 05/20/2015 | |
| Hsiao, Katherine | Corporate director | Individual | 01/01/2014 | |
| Kacher Cobb, Jill | Corporate director | Individual | 01/01/2019 | |
| Krevans, Sarah | Corporate director | Individual | 06/21/2012 | |
| Levy, Richard | Corporate director | Individual | 05/20/2015 | |
| O'Connell, Dennis | Corporate director | Individual | 01/01/2010 | |
| Oliver, Steven | Corporate director | Individual | 01/01/2010 | |
| Padval, Umesh | Corporate director | Individual | 01/01/2019 | |
| Ryan, John | Corporate director | Individual | 05/20/2015 | |
| Sinha, Ronesh | Corporate director | Individual | 05/20/2015 | |
| Taylor, Margaret | Corporate director | Individual | 05/20/2015 | |
| Varner, Jane | Corporate director | Individual | 01/01/2019 | |
| Vilardo, Elizabeth | Corporate director | Individual | 01/01/2019 | |
| Wagner, Anthony | Corporate director | Individual | 05/20/2015 | |
| Conforti, James | Corporate officer | Individual | 03/12/2012 | |
| Gates, John | Corporate officer | Individual | 01/01/2013 | |
| Hall, Karen | Corporate officer | Individual | 05/20/2015 | |
| Petrini, Julie | Corporate officer | Individual | 01/01/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.