Inspection citations
23’21
5’23
20’24
5’25
9’26
62 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 17, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 17, 2026 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jul 17, 2026 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 17, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 17, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 8, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| May 4, 2026 | 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 4, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Mar 4, 2026 | 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. | Complaint |
| Aug 13, 2025 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Aug 13, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 8, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 21, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 6, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 19, 2024 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Sep 19, 2024 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Sep 3, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 3, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Sep 3, 2024 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Jun 11, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 28, 2024 | G · harm | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Feb 28, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Feb 27, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 27, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 27, 2024 | D · potential | Post nurse staffing information every day. | Complaint |
| Feb 15, 2024 | E · potential | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Complaint |
| Feb 15, 2024 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Feb 15, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 15, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 15, 2024 | G · harm | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Feb 15, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 14, 2024 | E · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Jan 4, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jan 4, 2024 | D · potential | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Complaint |
| Nov 22, 2023 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Nov 22, 2023 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Nov 22, 2023 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Nov 22, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Nov 22, 2023 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 19, 2021 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| May 19, 2021 | E · potential | Give residents a notice of rights, rules, services and charges. | Routine |
| May 19, 2021 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| May 19, 2021 | H · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| May 19, 2021 | G · harm | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Routine |
| May 19, 2021 | G · harm | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| May 19, 2021 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 19, 2021 | E · 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 |
| May 19, 2021 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| May 19, 2021 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| May 19, 2021 | D · potential | Provide activities to meet all resident's needs. | Routine |
| May 19, 2021 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| May 19, 2021 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| May 19, 2021 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| May 19, 2021 | F · potential | 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. | Routine |
| May 19, 2021 | F · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Routine |
| May 19, 2021 | E · potential | Post nurse staffing information every day. | Routine |
| May 19, 2021 | 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 |
| May 19, 2021 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 19, 2021 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| May 19, 2021 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| May 19, 2021 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| May 19, 2021 | E · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 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
Professional Post Acute Center
81 Professional Center Parkway, San Rafael, CA 94903 · (415) 479-5161
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555214
- Certified beds
- 99
- Legal owner
- Cf San Rafael, LLC
- Part of
- Cambridge Healthcare Services
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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