Cycle 1
Health 2026-01-09 · Fire 2026-01-09
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Francisco, CA
California Pacific Medical Ctr- Davies Campus Hosp
5-star overall rating with 5-star inspections with $4,194 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
601 Duboce Ave, San Francisco, CA
(415) 600-6000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
25
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-10-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
6.66
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.05
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
9.18
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
6.71
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
8.58
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
6.08
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.41
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
4.66
CMS adjusted RN staffing hours
Adjusted total hours
6.43
CMS adjusted total nurse staffing hours
Case-mix index
1.95
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
85
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
87.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0270
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.84
Baseline 16.29% · Performance 17.80% · Measure score 7.84 · Achievement 7.84 · Improvement 0
Healthcare-associated infections
7.17
Baseline 5.38% · Performance 5.69% · Measure score 7.17 · Achievement 7.17 · Improvement 0
Total nurse turnover
10
Baseline 91.05% · Performance 16.95% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
10
Performance 5.98 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 11.45% · Lower 95% interval 7.66% |
| Discharge to community | 79.79% |
50.57%
29.2 pts better
|
Better than the National Rate · Eligible stays 133 · Observed rate 64.66% · Lower 95% interval 69.75% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.78% |
95.27%
0.5 pts worse
|
Numerator 109 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 31.11% |
53.69%
22.6 pts worse
|
Numerator 28 · Denominator 90 |
| Discharge mobility score | 31.11% |
50.94%
19.8 pts worse
|
Numerator 28 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 2.61% |
2.29%
0.3 pts worse
|
Numerator 3 · Denominator 115 · Adjusted rate 2.87% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 4.12% · Lower 95% interval 3.24% |
| Staff COVID-19 vaccination coverage | 53.49% |
8.2%
45.3 pts better
|
Numerator 23 · Denominator 43 |
| Staff flu vaccination coverage | 78.13% |
42%
36.1 pts better
|
Numerator 50 · Denominator 64 |
| Discharge function score | 34.44% |
56.45%
22 pts worse
|
Numerator 31 · Denominator 90 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 97.7% |
96.28%
1.4 pts better
|
Numerator 85 · Denominator 87 |
| Resident COVID-19 vaccinations up to date | 43.84% |
25.2%
18.6 pts better
|
Numerator 32 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who lose too much weight | 9.5% |
4.1%
5.4 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.9% |
13.7%
29.2 pts worse
|
19.6%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.9% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 17.9% |
1.0%
16.9 pts worse
|
1.0%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 14.3% |
1.2%
13.1 pts worse
|
1.7%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
94.0%
11.3 pts worse
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.2% · Q2 81.9% · Q3 84.6% · Q4 82.7% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
11.2%
6.6 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 5.6% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.7% · Q3 1.5% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
93.2%
3.4 pts worse
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
23.2%
4.3 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 21.6% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-04-28 · Fire 2023-04-28
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-02-10
F · Potential for more than minimal harm
2026-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-05
F · Potential for more than minimal harm
2026-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-02
F · Potential for more than minimal harm
2026-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-22
D · Potential for more than minimal harm
2026-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-19
D · Potential for more than minimal harm
2026-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-10
C · Minimal harm
2026-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-04
F · Potential for more than minimal harm
2024-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-24
C · Minimal harm
2024-07-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-24
F · Potential for more than minimal harm
2023-04-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-09
D · Potential for more than minimal harm
2023-04-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
$4,194
2023-05-23
Fine
Fine · fine $4,194
Fine
Ownership
Sutter Bay Hospitals
5% Or Greater Direct Ownership Interest · Organization
Sutter Health
5% Or Greater Indirect Ownership Interest · Organization
Bell, Diana
Corporate Director · Individual
Black, David
Corporate Director · Individual
Conforti, James
Corporate Director · Individual
Conforti, James
Corporate Officer · Individual
Deikel, Theodore
Corporate Director · Individual
Eisenhardt, Emil
Corporate Director · Individual
Flowers, Eric
Corporate Director · Individual
Gates, John
Corporate Officer · Individual
Gates, John
W-2 Managing Employee · Individual
Hall, Karen
Corporate Officer · Individual
Hill, Richard
Corporate Director · Individual
Hsiao, Katherine
Corporate Director · Individual
Kacher Cobb, Jill
Corporate Director · Individual
Krevans, Sarah
Corporate Director · Individual
Levy, Richard
Corporate Director · Individual
O'connell, Dennis
Corporate Director · Individual
Oliver, Steven
Corporate Director · Individual
Padval, Umesh
Corporate Director · Individual
Petrini, Julie
Corporate Officer · Individual
Petrini, Julie
W-2 Managing Employee · Individual
Ryan, John
Corporate Director · Individual
Sinha, Ronesh
Corporate Director · Individual
Taylor, Margaret
Corporate Director · Individual
Varner, Jane
Corporate Director · Individual
Vilardo, Elizabeth
Corporate Director · Individual
Wagner, Anthony
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hayes Convalescent Hospital
San Francisco, CA
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
San Francisco Health Care
San Francisco, CA
1-star overall rating with 1-star inspections with $152,404 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Central Gardens Post Acute
San Francisco, CA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out