Inspection citations
12’19
20’23
2’24
2’25
36 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Feb 20, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Feb 20, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Mar 8, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Mar 7, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Apr 21, 2023 | D · potential | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Routine |
| Apr 21, 2023 | D · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| Apr 21, 2023 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Apr 21, 2023 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Apr 21, 2023 | D · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Apr 21, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Apr 21, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Apr 21, 2023 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Apr 21, 2023 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Apr 21, 2023 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Apr 21, 2023 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Apr 21, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 21, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 21, 2023 | D · potential | 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. | Routine |
| Apr 21, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 21, 2023 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Apr 21, 2023 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Apr 21, 2023 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 21, 2023 | D · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Apr 21, 2023 | D · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Aug 23, 2019 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Aug 23, 2019 | E · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Aug 23, 2019 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Aug 23, 2019 | D · potential | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Routine |
| Aug 23, 2019 | G · harm | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Aug 23, 2019 | F · potential | Post nurse staffing information every day. | Routine |
| Aug 23, 2019 | G · harm | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Aug 23, 2019 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Aug 23, 2019 | E · potential | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Routine |
| Aug 23, 2019 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 23, 2019 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Routine |
| Aug 23, 2019 | F · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Victorian Post Acute
2121 Pine Street, San Francisco, CA 94115 · (415) 922-5085
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055848
- Certified beds
- 90
- Legal owner
- Golden Gateidence Opco LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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