Victorian Post Acute
2121 Pine Street, San Francisco, CA 94115
Victorian Post Acute is a nursing home in San Francisco, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (415) 922-5085
- Last standard health inspection
- February 20, 2025 (1 year ago)
- Certified beds
- 90
- Residents per day, on average
- 86.1
- Ownership type
- For profit - Corporation
- Legal business name
- Golden Gateidence Opco LLC
- Chain
- Pacs Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (36 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of June 25, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health citation
CMS changed citation F0686 from severity G to D. It is from the health inspection on April 21, 2023. Severity D: potential for more than minimal harm, isolated.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
2 citations
Health inspection on February 20, 2025
CMS lists this as a standard inspection.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 14, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for F0880 2 times since 2023.
4 citations
Fire safety inspection on February 20, 2025
CMS lists this as a standard inspection.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 25, 2025.
CMS has cited this home for K0353 3 times since 2019.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 25, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 25, 2025.
CMS has cited this home for K0920 2 times since 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 25, 2025.
CMS has cited this home for K0712 2 times since 2023.
CMS update of August 29, 2024
Ownership
CMS lists this home under a new chain.
1 citation
Health inspection on March 8, 2024
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 5, 2024.
1 citation
Health inspection on March 7, 2024
CMS lists this as a complaint inspection.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on June 5, 2024.
CMS has cited this home for F0697 2 times since 2019.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
20 citations
Health inspection on April 21, 2023
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 2, 2023.
CMS has cited this home for F0812 2 times since 2019.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on June 2, 2023.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 2, 2023.
Citation F0813. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on June 2, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on June 2, 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 2, 2023.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on June 2, 2023.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on June 2, 2023.
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on June 2, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on June 2, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 2, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 2, 2023.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on June 2, 2023.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on June 2, 2023.
CMS has cited this home for F0745 2 times since 2019.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 2, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 2, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 2, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 2, 2023.
Citation F0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
CMS lists it as corrected on June 2, 2023.
CMS has cited this home for F0912 2 times since 2019.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on June 2, 2023.
14 citations
Fire safety inspection on April 21, 2023
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on May 11, 2023.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on May 11, 2023.
CMS has cited this home for E0041 2 times since 2019.
Citation K0347. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on May 11, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 11, 2023.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 11, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 11, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 11, 2023.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 11, 2023.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on May 11, 2023.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on May 11, 2023.
CMS has cited this home for K0291 2 times since 2019.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on May 11, 2023.
Citation K0346. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on May 11, 2023.
Citation K0354. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on May 11, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 11, 2023.
CMS has cited this home for K0363 2 times since 2019.
12 citations
Health inspection on August 23, 2019
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
10 of 1,165 California homes (under 1%) got a citation at the actual harm level in 2019.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on November 7, 2019.
Citation F0745. Severity G: actual harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on November 7, 2019.
Citation F0732. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on November 7, 2019.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 7, 2019.
Citation F0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
CMS lists it as corrected on November 7, 2019.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on November 7, 2019.
Citation F0806. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on November 7, 2019.
Citation F0808. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 7, 2019.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 7, 2019.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 7, 2019.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on November 7, 2019.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on November 7, 2019.
9 citations
Fire safety inspection on August 23, 2019
CMS lists this as a standard inspection.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on October 15, 2019.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 15, 2019.
Citation E0041. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on October 15, 2019.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on October 15, 2019.
Citation K0225. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on October 15, 2019.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on October 15, 2019.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 15, 2019.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 15, 2019.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 15, 2019.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BAY AREA MASTER TENANT LLC5% or greater direct ownership interest · 100% · since 09/01/2017
- JERGENSEN, JOSHUAOperational/managerial control · not applicable · since 01/01/2024
- MITCHELL, JOHNOperational/managerial control · not applicable · since 01/01/2024
- PORTIER, DAVIDOperational/managerial control · not applicable · since 01/01/2019
- RUSSELL, MATTHEWOperational/managerial control · not applicable · since 01/07/2019
Questions
When was Victorian Post Acute last inspected?
CMS lists February 20, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Victorian Post Acute have?
CMS lists 36 health citations since August 23, 2019. CMS also calls these deficiencies.
Has Victorian Post Acute been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Victorian Post Acute?
Its CMS overall star rating is 5 of 5.
Is Victorian Post Acute a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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