Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at City View Post Acute during CMS and state inspections, most recent first.
Multiple staff and residents reported ongoing cockroach infestations in several rooms, with live and dead cockroaches observed in resident areas and food storage locations. Some rooms with reported infestations were not included in pest control or deep cleaning schedules, despite the facility's policy and pest control agreement indicating a need for ongoing and facility-wide pest management.
A resident with multiple medical and mental health conditions reported a black pouch containing cash missing after returning from the hospital. The resident had previously shown a CNA $1,000 in the pouch, but the cash was not documented in the inventory or secured as required by facility policy. The loss of the cash caused the resident significant emotional distress, including sadness and distrust toward staff.
A resident with multiple medical and mental health diagnoses reported a missing black pouch containing cash after a hospital transfer. Despite a CNA confirming the presence of $1,000 in the pouch and returning it to the resident prior to its disappearance, the facility did not document the cash in the resident's inventory or take further action after the CNA's verification. The resident experienced emotional distress, and the facility's required procedures for safeguarding and inventorying valuables were not followed.
A resident with moderate cognitive impairment and diagnoses of hypertension and pulmonary embolism was allowed to self-administer Eliquis and Metoprolol without an assessment or care plan from the interdisciplinary team, contrary to facility policy requiring such evaluation and approval.
A resident was found with visibly dirty fingernails containing black matter underneath, and reported that staff had not cleaned her nails despite her requests. An LVN confirmed the nails were dirty and noted the infection risk, while the DON stated that CNAs are responsible for daily nail care. Facility policy requires daily cleaning and regular trimming of nails to prevent infection.
Two residents experienced ongoing issues due to the facility's failure to assess, monitor, and implement care plans for sleep disturbances and behavioral symptoms. One resident with cancer and diabetes was unable to sleep because of another resident's persistent yelling, with no effective interventions or care planning provided. Another resident with dementia and encephalopathy exhibited frequent yelling, paranoia, and insomnia, but these behaviors were not addressed through care planning or accurately documented in the MDS.
The facility failed to refer two residents for a Level II PASARR evaluation after they were diagnosed with new mental illnesses. One resident, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but no referral was made. Another resident, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, but was not referred for evaluation. The facility's policy lacked procedures for handling new mental illness diagnoses, and the DON stated that a new PASARR would only be conducted if the mental illness caused a significant change in the resident's condition.
A facility failed to complete a new Level I PASARR screening for a resident with schizophrenia, as required by policy. The resident was admitted with a history of schizophrenia and was on antipsychotic medication, necessitating a Level II evaluation. The California DHCS could not complete the evaluation due to the facility's unresponsiveness to communication attempts. The DON admitted the facility missed calls and did not follow instructions to redo the Level I PASARR, leading to the deficiency.
A resident with severe cognitive impairment was discharged with another resident's medications due to a failure in medication reconciliation. The LVN did not verify the contents of the medication bag against the discharge list, leading to the error being discovered when the resident's sister returned the incorrect medications to the facility.
A resident with chronic pain syndrome experienced a delay in receiving an MRI due to a breakdown in communication and failure to follow facility policy. The physician's order was not promptly acted upon, leading to a re-order and delayed diagnostic imaging.
A resident with COPD did not receive their prescribed Trelegy Ellipta inhaler on multiple occasions due to the medication being out of stock. The DON confirmed that the medication was not reordered in a timely manner, despite facility policy requiring advance ordering. This created a risk for poor health outcomes for the resident.
The facility failed to ensure effective communication and proper care planning for a resident, leading to missed doctor's appointments and inadequate family communication. The resident's son reported unreturned calls and texts, and the facility mismanaged transportation arrangements, impacting the resident's clinical condition and well-being.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss due to being placed on a Controlled Carbohydrate Diet (CCHO) despite not being diabetic. The facility staff failed to adequately monitor and address the resident's nutritional needs, leading to a decline in the resident's health and well-being.
A resident without a diabetes diagnosis received unnecessary insulin and blood glucose monitoring. The facility's failure to follow its medication administration policy and mismanagement of the resident's drug regimen potentially compromised the resident's well-being.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff and resident reports of cockroach infestations in several resident rooms. During an observation, live and dead cockroaches were found in a resident's room, including on the floor, trash bin, nightstand, and inside a nightstand drawer containing food items. Food particles and brownish discolorations were also noted on the floor. Staff, including CNAs and LVNs, acknowledged the ongoing presence of cockroaches throughout the facility, with one CNA stating that every room had roaches. Housekeeping staff confirmed that some rooms had been fumigated and cleaned, but sightings persisted, and not all affected rooms were included in the cleaning or fumigation schedule. A resident reported seeing multiple cockroaches in his room and stated that his room had not been fumigated or inspected by pest control after he raised the issue during a resident council meeting. Review of pest control service reports and facility cleaning schedules confirmed that certain rooms with reported infestations were not serviced or deep cleaned. The facility's pest control agreement indicated a primary concern of active cockroach infestation with facility-wide risk, but documentation showed that only a limited number of rooms were serviced per visit, and some affected rooms were omitted. The facility's policy required ongoing pest control, but the observed and reported conditions demonstrated a failure to implement an effective program.
Failure to Safeguard Resident's Personal Property and Document Valuables
Penalty
Summary
The facility failed to safeguard the personal property of a resident who reported a black pouch containing cash missing after being readmitted from the hospital. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, stated that the pouch with $2,000 was left in his room prior to hospitalization. The resident had previously shown a CNA $1,000 in the pouch, and the CNA confirmed witnessing this amount. However, the pouch and cash were not documented in the resident's inventory of personal effects as required by facility policy. Upon the resident's return, he reported the missing pouch and cash, expressing significant emotional distress, including sadness, tearfulness, and feelings of distrust toward staff. Multiple staff interviews and record reviews confirmed that the CNA had seen the pouch and cash but failed to update the inventory or ensure the valuables were secured in the facility's safe, as per policy. The resident continued to experience emotional distress related to the loss, requiring ongoing support from the social worker and referral to a psychologist. The facility's investigation did not find evidence of wrongdoing by staff, residents, or visitors, and the missing items were not recovered. The CNA involved received in-service training on the proper process for documenting resident property and the facility's procedures for safeguarding valuables. Despite these measures, the initial failure to document and secure the resident's cash resulted in its loss and ongoing emotional impact on the resident.
Failure to Investigate and Safeguard Resident's Missing Cash
Penalty
Summary
The facility failed to thoroughly investigate a resident's report of missing personal property, specifically a black pouch containing cash. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, reported that the pouch with approximately $2,000 was missing following a transfer to the hospital. The resident had previously shown a Certified Nursing Assistant (CNA) $1,000 in the pouch, and the CNA confirmed seeing and returning the pouch to the resident in the weeks prior to its disappearance. However, the pouch and cash were not documented in the resident's inventory, and the facility did not take further action after the CNA verified the presence of the cash. The investigation conducted by the facility included interviews with staff and review of documentation, but no evidence or report of wrongdoing by staff, residents, or visitors was found. The interdisciplinary team determined that the allegation was unverified, and the missing items were not recovered. The CNA involved received training on the proper process for documenting resident property and the facility's policy for safeguarding valuables, but this was after the incident had occurred. Throughout the process, the resident experienced significant emotional distress, including tearfulness, sadness, and feelings of distrust toward staff. The resident continued to express sadness and depression related to the loss of the cash, and social services provided ongoing support and referred the resident to a psychologist. The facility's policies required inventorying resident belongings and safeguarding valuables, but these procedures were not followed in this case, contributing to the loss and the resident's emotional response.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
A resident with a history of hypertension and pulmonary embolism, and documented moderate cognitive impairment, was observed self-administering medications without the required assessment and approval from the interdisciplinary care planning team. The resident had an unlabeled transparent medicine cup containing two tablets, which she identified as Eliquis and Metoprolol, on her overbed table. She reported that a nurse had left the medications for her earlier so she could take them later. Review of the resident's clinical records by the Director of Nursing confirmed that there was no documented evaluation or care plan for self-administration of medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary team have determined the resident has the decision-making capacity to do so safely. This policy was not followed in this instance.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
A deficiency was identified when a resident's fingernails were observed to be unclean, with black-colored matter present under all fingernails. The resident reported that no one had come to clean her nails despite her repeated requests, expressing dissatisfaction with the condition of her nails. During the observation, an LVN confirmed the presence of dirt under the nails and acknowledged that this could be an infection issue, emphasizing the need to keep nails clean to prevent infection. The DON stated that CNAs are responsible for daily cleaning of residents' fingernails to prevent infection. Review of the facility's policy indicated that daily cleaning and regular trimming of nails are required to prevent infections and skin problems around the nail bed.
Failure to Address Sleep Disturbances and Behavioral Symptoms
Penalty
Summary
The facility failed to provide appropriate care and treatment for two residents with significant needs. One resident, admitted with diagnoses including squamous cell carcinoma and diabetes, reported ongoing difficulty sleeping due to another resident's persistent yelling and screaming at all hours. Despite repeated complaints to nursing, social work, and management, the only intervention provided was a headphone, which was ineffective. There was no assessment, monitoring, or care plan developed to address the resident's sleep difficulties, and the grievance was not documented or addressed according to facility policy. Another resident, diagnosed with dementia and encephalopathy, exhibited ongoing behavioral disturbances including yelling, screaming, paranoia, and insomnia. Staff interviews and record reviews confirmed that these behaviors were persistent and disruptive, occurring day and night, and were documented in multiple psychiatry notes. Despite this, there was no care plan or interventions implemented to address the resident's insomnia and paranoia, and the behaviors were not accurately reflected in the Minimum Data Set (MDS) assessments. The facility's interdisciplinary team did not evaluate or monitor these behavioral symptoms as required by policy. Facility policies reviewed indicated requirements for accommodating resident needs, providing a homelike environment, addressing grievances, and developing comprehensive, person-centered care plans based on thorough assessments. However, these policies were not followed in the cases of the two residents, resulting in unaddressed sleep disturbances for one and unmanaged behavioral symptoms for the other. The lack of assessment, care planning, and intervention contributed to ongoing issues for both residents.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer two residents to the appropriate state-designated authority for a Level II PASARR evaluation after they were diagnosed with newly evident mental illnesses. Resident #56, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but there was no evidence of a referral for a Level II PASARR. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the care plan included the diagnosis of psychotic disorder. Similarly, Resident #86, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, psychosis, and adjustment disorder with anxiety, but was not referred for a Level II PASARR. The resident's MDS showed severe cognitive impairment, and the care plan noted the use of psychotropic medication for the psychotic disorder. The facility's policy on admissions criteria did not specify procedures for staff to follow when a resident is diagnosed with a new or possible serious mental disability. During interviews, the Director of Nursing (DON) stated that a new Level I PASARR would be conducted if a resident received a new mental illness diagnosis. However, the DON indicated that a new PASARR would only be done if the severe mental illness caused a significant change in the resident's condition, which was not the case for Residents #56 and #86. This lack of referral for a Level II PASARR evaluation represents a deficiency in the facility's compliance with regulatory requirements for preadmission screening and resident review.
Failure to Complete PASARR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to complete a new Level I PASARR screening for a resident with a diagnosis of schizophrenia, as required by the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If the Level I screening suggests the presence of such conditions, a referral for a Level II evaluation is necessary. The resident in question was admitted with a medical history of schizophrenia and was receiving haloperidol, an antipsychotic medication, indicating the need for a Level II evaluation. The California Department of Health Care Services (DHCS) attempted to conduct a Level II evaluation but was unable to complete it due to the facility's lack of response to multiple communication attempts. A letter from DHCS indicated that the facility staff did not respond to two or more separate attempts within 48 hours following the resident's Level I screening. The Director of Nursing acknowledged that the facility missed the calls and failed to follow the instructions in the letter to redo the Level I PASARR, resulting in the deficiency.
Medication Reconciliation Error at Discharge
Penalty
Summary
The facility failed to accurately reconcile post-discharge medications for a resident, leading to the resident being discharged with another resident's medications. This incident involved a resident with a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The discharge summary note indicated that the resident was discharged with a Post-Discharge Plan of Care form filled out and signed by the patient, with all medications and follow-up appointments reviewed. However, the Licensed Vocational Nurse (LVN) responsible for the discharge did not open the bag of medications to verify its contents against the discharge medication list. The error was discovered when the resident's sister returned to the facility with a bag of medications labeled for a different resident. The Nurse Manager confirmed that the returned medications were intended for another resident, as evidenced by the labels on the blister packs. The Director of Nursing stated that the expectation was for nursing staff to verify the medications against the discharge list before discharge, which was not done in this case.
Failure to Timely Execute Physician's Order for MRI
Penalty
Summary
The facility failed to provide necessary care and services to a resident when a physician's order for an MRI was not carried out in a timely manner. The resident, who suffers from chronic pain syndrome, expressed severe pain and a desire to understand the cause of their condition, including concerns about potential cancer. Despite the physician ordering an MRI on 3/25/24, the order was not acted upon promptly. The night nurse saw the order on 3/26/24 but did not inform the social worker responsible for outpatient referrals. This oversight led to the MRI not being scheduled, and the physician had to re-order it on 4/17/24. Interviews with the resident, LVN, SW, and DON revealed that the breakdown in communication and failure to follow the facility's policy on medication and treatment orders contributed to the delay. The DON confirmed that the physician's order should have been communicated to the appropriate staff and carried out as soon as possible. The facility's policy requires licensed nurses to record and act on physician orders immediately, but this protocol was not followed, resulting in a delay in the resident receiving the necessary diagnostic imaging.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure that prescribed medication was available for administration to a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who relies on a Trelegy Ellipta inhaler to manage their condition, reported experiencing chronic shortness of breath. A review of the resident's Medication Administration Record (MAR) revealed that the inhaler was not administered on multiple occasions in February 2024 due to the medication being out of stock. The Director of Nursing (DON) confirmed that the medication was not given because it had not been reordered in a timely manner by the licensed nurses, despite the facility's policy requiring medications to be ordered in advance based on the pharmacy's lead time. During an interview, the DON acknowledged that the failure to have the Trelegy Ellipta inhaler available could worsen the resident's respiratory symptoms and emphasized the importance of communication with the doctor. The resident's progress notes indicated that the medication was out of order on several dates, and although it was reordered, it was not available for administration. This lapse in medication management created a risk for poor health outcomes for the resident.
Communication and Transportation Failures
Penalty
Summary
The facility failed to ensure effective communication and proper care planning for Resident-A, leading to significant deficiencies. Resident-A's son reported that the social worker did not return his calls or texts on five different occasions, which hindered communication about his father's care. Additionally, the facility mismanaged transportation arrangements, resulting in the cancellation of Resident-A's doctor's appointments on two separate dates. This lack of coordination and communication potentially impacted Resident-A's clinical condition and psychosocial well-being. Resident-A was admitted with multiple diagnoses, including cerebral infarction, enterocolitis due to clostridium difficile, urinary tract infection, type 2 diabetes, and frequent falls. His cognitive skills were moderately impaired, as indicated by a BIMS score of 9. Despite these complex medical needs, the facility failed to ensure that Resident-A's appointments were kept and that his family was adequately informed about his care. The social worker's failure to return calls and the facility's disorganized transportation scheduling contributed to these deficiencies. Interviews with facility staff, including the social worker and the director of nursing, revealed a lack of accountability and documentation regarding the missed appointments and communication failures. The transportation company also indicated that they were not solely responsible for the missed appointments, as the facility used multiple transportation providers and often made last-minute requests. The facility's policies on transportation and resident rights were not effectively implemented, leading to the observed deficiencies in Resident-A's care and communication with his family.
Failure to Meet Nutritional Needs of Non-Diabetic Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who was not diabetic but was placed on a Controlled Carbohydrate Diet (CCHO) since admission. This resident, who had severe cognitive impairment and multiple diagnoses including burns, hyperkalemia, and dysphagia, experienced a significant weight loss of almost 10 lbs. from September 24, 2023, to November 17, 2023. The resident's clinical record did not indicate diabetes mellitus as a diagnosis, and the CCHO diet order was carried over from the hospital without proper verification by the facility staff. The resident's poor appetite and significant weight loss were not adequately addressed by the facility's dietary and medical staff, leading to a decline in the resident's clinical health and well-being. Interviews with various staff members, including the unit managers, social worker, dietary manager, and registered dietitian, revealed a lack of awareness and coordination regarding the resident's dietary needs and weight loss. The dietary manager and registered dietitian were new to the facility and were not fully informed about the resident's condition and dietary requirements. The registered dietitian noted that the resident had a poor appetite and was on a puree texture diet with Boost supplements three times a day, but the resident's meal intake was only about 51%. The resident's daughter also confirmed that her mother was placed on a diabetic diet despite not being diabetic and that her mother's weight and appetite improved after being discharged and cared for at home. The facility's policies on weight assessment and intervention were not effectively implemented, as evidenced by the lack of timely and appropriate actions to address the resident's significant weight loss. The care plan for the resident included multiple focus areas such as nutritional risk, nausea and vomiting, dehydration, and weight loss, but the interventions were not adequately followed. The facility's failure to monitor and address the resident's nutritional needs and weight loss in a timely manner resulted in a decline in the resident's health and well-being.
Unnecessary Drug Administration and Mismanagement of Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that a resident, who had no diagnosis of diabetes mellitus, was free from unnecessary drugs and interventions. The resident was admitted with diagnoses including burns, hyperkalemia, and dysphagia, but not diabetes. Despite this, the resident had an order for a sliding scale of insulin Lispro and received it multiple times. Additionally, the resident's blood glucose was checked three times a day over a period of nearly a month, with levels ranging from 112 to 188. The resident was also placed on a Controlled Carbohydrate diet, which was later discontinued by a new registered dietitian who noted the resident's poor appetite and weight loss. The resident's daughter confirmed that her mother was not diabetic and questioned the blood sugar checks and diabetic diet. The facility's medical doctor acknowledged that the resident's hemoglobin A1C was 6, which is considered pre-diabetic according to the American Diabetes Association, and not diabetic. The MD stated that the sliding scale insulin was discontinued because the resident was well-controlled, but it was unclear who had initially ordered it. The facility's policy on administering medications emphasizes that medications should be administered as prescribed and that any concerns about inappropriate or excessive dosages should be discussed with the prescriber. However, this policy was not followed in the case of this resident. The facility's failure to adhere to its own medication administration policy and the mismanagement of the resident's drug regimen potentially compromised the resident's mental, physical, and psychosocial well-being. The care plan for the resident included a diagnosis of diabetes, which was incorrect according to the resident's daughter and the medical records. This misdiagnosis led to unnecessary interventions, including insulin administration and blood glucose monitoring, which were not clinically indicated for the resident's actual medical condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Francisco Towers | 0 mi | — | 12 | 0 |
| Victorian Post Acute | 0.6 mi | — | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.6 mi | — | 13 | 0 |
| Chinese Hospital D/p Snf | 0.7 mi | — | 19 | 0 |
| Central Gardens Post Acute | 0.7 mi | — | 0 | 0 |
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