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
Staffing
Hours and turnover
RN hours / resident day
1.98
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
4.55
Nurse aide staffing
Weekend hours
5.68
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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Northgate Postacute Care
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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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