Federal inspection record · CMS data as of October 1, 2026
The Avenues Transitional Care Center
2043 19th Avenue, San Francisco, CA · (415) 661-8787
- Certified beds
- 140
- Residents per day
- 134
- Ownership
- For-Profit
- Chain
- Aspen Skilled Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- March 29, 1974
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
The Avenues Transitional Care Center carries 69 inspection points. That is fewer than 64% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
21 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Pharmacy Service5E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure 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.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Ensure 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.
Resident Rights4D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Nutrition and Dietary3F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Resident Assessment and Care Planning3D
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care2E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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.
Environmental2C
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Infection Control1E
- E
Provide and implement an infection prevention and control program.
Inspection history
2025-03-24
12 health deficiencies · 10 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2024-01-26
1 health deficiencies · 11 fire-safety deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2021-04-09
8 health deficiencies · 4 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 55 min of nursing staff time a day, 50 min of it from a registered nurse.
This home
3 h 55 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 40% of nursing staff and 35% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$12,685 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-10-02 | Fine | $12,685 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.9 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts worse | 2.4 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 100.0% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.4 pts better | 1.2% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.6 pts better | 6.0% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts better | 2.3% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication10.2 pts better | 3.5% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.8 pts better | 8.5% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened4.3 pts better | 4.6% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7 pts better | 3.2% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 0.0% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1 pts better | 0.2% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.6 pts worse | 15.4% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3 pts better | 1.3% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.4 pts better | 100.0% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2 pts better | 9.1% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 0.8% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.9 pts better | 100.0% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3 pts better | 19.6% | 22.6% | 23.4% |
·
Who owns and runs it
39 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Asjk LLC | Direct Ownership Interest · Organization | 0% | 1 facilities |
| Asjk LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Asjk LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Aspen Healthcare Services LLC | Adp Of The SNF · Organization | 0% | 33 facilities |
| Aspen Skilled Healthcare Inc | Indirect Ownership Interest · Organization | 0% | 18 facilities |
| Basa, Edil | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Basa, Edil | Adp Of The SNF · Individual | 0% | 1 facilities |
| Bradshaw, Jeffrey | Indirect Ownership Interest · Individual | 0% | 34 facilities |
| Bradshaw, Jeffrey | Operational/Managerial Control · Individual | 0% | 34 facilities |
| Bradshaw, Jeffrey | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 34 facilities |
| Bradshaw, Jeffrey | Adp Of The SNF · Individual | 0% | 34 facilities |
| Bradshaw, Peter | Indirect Ownership Interest · Individual | 0% | 31 facilities |
| Brady, Vern | Indirect Ownership Interest · Individual | 0% | 32 facilities |
| Brady, Vern | Adp Of The SNF · Individual | 0% | 32 facilities |
| Case, Ryan | Indirect Ownership Interest · Individual | 0% | 31 facilities |
| Case, Ryan | Operational/Managerial Control · Individual | 0% | 31 facilities |
| Case, Ryan | Adp Of The SNF · Individual | 0% | 31 facilities |
| Elsner, Eric | Indirect Ownership Interest · Individual | 0% | 30 facilities |
| Go, Maria | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Go, Maria | Adp Of The SNF · Individual | 0% | 1 facilities |
| Jamali, Mehran | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Jamali, Mehran | Adp Of The SNF · Individual | 0% | 5 facilities |
| Jurado, Frank | Adp Of The SNF · Individual | 0% | 31 facilities |
| Kirkwood, Jared | Indirect Ownership Interest · Individual | 0% | 31 facilities |
| Orgill, Craig | Indirect Ownership Interest · Individual | 0% | 31 facilities |
| Orgill, Craig | Operational/Managerial Control · Individual | 0% | 31 facilities |
| Parti, Rajesh | Indirect Ownership Interest · Individual | 0% | 30 facilities |
| Parti, Shruty | Indirect Ownership Interest · Individual | 0% | 29 facilities |
| Paxman, Marcus | Indirect Ownership Interest · Individual | 0% | 32 facilities |
| Paxman, Marcus | Adp Of The SNF · Individual | 0% | 32 facilities |
| Rawe, Colton | Managing Control - Governing Body · Individual | 0% | 18 facilities |
| Rawe, Colton | Operational/Managerial Control · Individual | 0% | 18 facilities |
| Rawe, Colton | Adp Of The SNF · Individual | 0% | 18 facilities |
| Sequoia Healthcare Group LLC | Indirect Ownership Interest · Organization | 0% | 19 facilities |
| Sequoia Healthcare Group LLC | Adp Of The SNF · Organization | 0% | 19 facilities |
| Skbm Ii LLC | Indirect Ownership Interest · Organization | 0% | 1 facilities |
| Skbm Ii LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Skbm LLC | Indirect Ownership Interest · Organization | 0% | 4 facilities |
| Skbm LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
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Fire safety
25 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke9E
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install corridor and hallway doors that block smoke.
- D
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install corridor and hallway doors that block smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems5F
- D
Meet requirements for the use of electrical equipment.
- D
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the use of electrical equipment.
- E
Have generator or other power source capable of supplying service within 10 seconds.
Egress3D
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Miscellaneous3D
- D
Provide a written emergency evacuation plan.
- C
Have simulated fire drills held at unexpected times.
- D
Provide a written emergency evacuation plan.
Emergency Preparedness3F
- C
Conduct testing and exercise requirements.
- F
Provide family notifications of emergency plan.
- D
Provide emergency officials' contact information.
Construction2D
- D
Use approved construction type or materials.
- D
Use approved construction type or materials.
·
Other homes nearby
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Laguna Honda Hospital & Rehabilitation Ctr D/P SNF
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★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 5 h 2 min
- Fines
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-
Lawton Skilled Nursing & Rehabilitation Center
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- Nursing / resident / day
- 4 h 40 min
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-
St. Anne's Home
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