Cycle 1
Health 2025-11-18 · Fire 2025-11-18
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
San Rafael, CA
Villa Marin
5-star overall rating with 4-star inspections with $7,443 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
100 Thorndale Drive, San Rafael, CA
(415) 492-2408
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
31
Certified beds
Average residents
12
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-07-09
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.98
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
4.55
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
7.35
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.79
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
5.68
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.33
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.07
CMS adjusted RN staffing hours
Adjusted total hours
7.70
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,141
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9990
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.70
Performance 19.25% · Measure score 4.70 · Achievement 4.70 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.26
Performance 6.26% · Measure score 5.26 · Achievement 5.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.77
Baseline 26.92% · Performance 48.28% · Measure score 3.77 · Achievement 3.77 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 6.14% |
| Discharge to community | 54.78% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 56.41% · Lower 95% interval 44.55% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 16 · Denominator 24 |
| Discharge mobility score | 58.33% |
50.94%
7.4 pts better
|
Numerator 14 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 2.64% |
| Staff COVID-19 vaccination coverage | 82.35% |
8.2%
74.1 pts better
|
Numerator 112 · Denominator 136 |
| Staff flu vaccination coverage | 71.33% |
42%
29.3 pts better
|
Numerator 102 · Denominator 143 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 15 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
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 have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
13.7%
5.4 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| 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 | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
10.9%
2.1 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
4.7%
2.9 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
93.2%
11.4 pts worse
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-18 · Fire 2023-08-18
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-03-01 · Fire 2019-03-01
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-11-18
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-10-24
F · Potential for more than minimal harm
2023-08-18
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-18
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-28
D · Potential for more than minimal harm
2019-03-01
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-12-09
F · Potential for more than minimal harm
2025-11-18
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 2025-12-09
E · Potential for more than minimal harm
2025-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-11-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-12-09
D · Potential for more than minimal harm
2024-04-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-10
G · Actual harm
2023-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-18
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-18
F726 · Nursing and Physician Services Deficiencies
Health
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 2023-09-18
E · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-18
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-18
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-09-18
F · Potential for more than minimal harm
2019-03-01
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 2019-04-18
E · Potential for more than minimal harm
2019-03-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-04-18
E · Potential for more than minimal harm
2019-03-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-04-18
E · Potential for more than minimal harm
2019-03-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-04-18
D · Potential for more than minimal harm
2019-03-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-04-18
D · Potential for more than minimal harm
2019-03-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-04-18
Penalties and ownership
What sits behind the stars
$7,443
2023-08-18
Fine
Fine · fine $7,443
Fine
Ownership
Havel, Milan
Corporate Officer · Individual
Havel, Milan
W-2 Managing Employee · Individual
Stephens, Patricia
W-2 Managing Employee · Individual
Walker, Daniel
Corporate Officer · Individual
Walker, Daniel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Northgate Postacute Care
San Rafael, CA
2-star overall rating with 2-star inspections with $129,101 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Pine Ridge Care Center
San Rafael, CA
4-star overall rating with 2-star inspections with $7,542 in total fines with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Professional Post Acute Center
San Rafael, CA
2-star overall rating with 1-star inspections with $283,454 in total fines with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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