San Francisco Health Care
SAN FRANCISCO HEALTH CARE in SAN FRANCISCO, CA — inspection on April 28, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 2's medical record titled MDS (Minimum Data Set, a standardized resident assessment tool), dated 1/4/26, indicated her BIMs (a 0-15 point test/assessment tool used to check a resident's memory and thinking abilities) score was 5 out of 15 (a score of 5 indicates severe problems with memory and thinking).
Review of Resident 2's hospital discharge record titled D/C planning Ongoing Assessment, dated 9/27/24, indicated .Discharge To: Skilled nursing facility. (social worker) discussed with . (admission staff ) at San Francisco Health Care Center regarding .(Resident 2's) valuables. reported .(Resident 2) having $3600 in US dollars, a yellow necklace and bracelet, and two [NAME] pendants . (admission staff at San Francisco Health Care Center) documented and will put in safe place and return upon discharge.
During an interview on 04/21/2026 at 1:55 PM, the Social Worker (SW) stated she was made aware of the missing money and jewelry by Resident 2's family member on March 17, 2026.
The SW stated she started to investigate the case and based on Resident 2 arriving without any belongings from the hospital, the SW concluded the facility was not responsible for these missing items.
The SW was asked if she was aware the hospital documented on 9/27/24 Resident 2 was to be discharged with $3,600 and jewelry.
The hospital also documented they spoke with a facility admission staff (Admission) to lock these valuables for safe keeping.
The SW said she interviewed the admission staff.
The SW stated the admission staff said she did not remember the phone conversation with the hospital and does not remember if money and valuables were discussed with the hospital during Resident 2's discharge.
The SW said during her investigation, the ombudsman translated for Resident 2 and Resident 2 stated upon arrival at the facility, she gave her money and jewelry to a Vietnamese man.
The SW stated they did not have a Vietnamese man working at the facility during that time frame.
The SW stated Resident 2 has never mentioned her money and jewelry since admission and this issue only came up when her family member asked about the money and jewelry.
During an interview 4/9/26 at 3:30 PM with the Administrator, DON, and SW, issues with the facility's inventory system and safeguarding of resident's belongings were shared with the facility's management team.
The following were discussed: There were issues identified with Residents 3 and 4 regarding their inventories (see above).
This may indicate a recent problem or an ongoing systemic problem with the facility's inventory system and/or safeguarding of resident's belongingsThere was evidence CNA 1 was treating monetary transactions between him and Resident 1 as between two consenting adults. By bypassing management oversight, this creates an environment where the facility may not be able to safeguard belongings of vulnerable residents.There was an independent source (hospital staff) documenting Resident 2 was coming to the facility with money and jewelry.
There was no documented evidence the facility followed up and investigated when Resident 2 arrived at the facility without her money and jewelry.
The facility stated they were not aware of item 3 and will submit their investigation regarding item 3.
The facility did not discuss or offered any new documentation regarding items 1 and 2.
Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property.
Providing measures to safeguard resident valuables from easy public access.Inventorying resident belongings upon admission .
056272 04/28/2026
San Francisco Health Care 1477 Grove Street San Francisco, CA 94117
During an interview on 4/10/26 at 12:11PM, the Administrator stated he was aware of R1RP's concerns thru phone calls and text messages but could not remember when he was first made aware of these allegations.
When the Administrator was asked does March 17, 2026, sound about right? The Administrator answered sound about right.
The Administrator was asked if he called this allegation in within 24 hours of learning about the allegation? The Administrator stated no.
During an interview on 4/8/26 at 9:10 AM, the Complainant stated Resident 2 alleged she was missing approximately $3,000 and some jewelry.
During an interview on 4/21/2026 at 1:55 PM, the Social Worker (SW) stated she was made aware of the missing money and jewelry by Resident 2's family member on March 17, 2026.
Review of California Department of Public Health (CDPH) electronic data for facility reported incidents from March 17 to April 21 found no evidence the facility reported Resident 2's allegation to CDPH.
Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property.Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incidents, as appropriate .
056272 04/28/2026
San Francisco Health Care 1477 Grove Street San Francisco, CA 94117
During an interview 4/9/26 at 3:30 PM with the Administrator, DON, and SW, issues with the facility's inventory system and safeguarding of resident's belongings were shared with the facility's management team.
The following were discussed: There was evidence CNA 1 was treating monetary transactions between him and Resident 1 as between two consenting adults.
There was no documentation the investigation expanded the sample to look at residents under CNA 1's care.
There was no documented evidence the investigation looked into what type of relationship CNA 1 had with Resident 1.There was an independent source (hospital staff) documenting Resident 2 was coming to the facility with money and jewelry.
There was no documented evidence the facility followed up and investigated when Resident 2 arrived at the facility without her money and jewelry.
After discussing these issues, the facility offered no other documents regarding these issues.
Except to say they will be submitting their investigation and conclusion regarding Resident 2's issues. On 4/22/26, at 10:03 AM, the SW was asked to submit all raw data and her investigations and conclusions regarding Resident 2's allegations.
Review of the untitled and undated documents sent by SW regarding Resident 2's allegations found these issues:There was no attempt to contact the transporting company regarding what item(s) Resident 2 brought from the hospital.The facility's conclusion was weighted heavily on Resident 2's statement she handed over her money and jewelry to a Vietnamese man upon admission.
The investigator accepted this statement was from a resident with an assessed severe memory problem.
Expansion of the sample may be necessary in this case instead of concluding all elements of Resident 2's statements were false.
There was no evidence the facility expanded their sample to look at other residents' belongings surrounding the admission staff identified in Resident 2's allegation.
Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property.
Providing measures to safeguard resident valuables from easy public access.
The investigation shall consist of at least the following:An interview with any witnesses that may have knowledge of the missing items . interviews with staff members (on all shifts) having contact with the resident during the past 48 hours.interview with the resident's roommate, family members, and visitors.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.