Central Gardens Post Acute

Name: Central Gardens Post Acute
Address: 1355 ELLIS STREET, San Francisco, CA, 94115, US
Telephone: 4155672967

1355 Ellis Street, San Francisco, CA 94115 · San Francisco County · 92 certified beds · avg 88 residents/day · certified since Jan 1, 1967

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

5/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.37

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (26)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Feb 20, 2025	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Feb 20, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 20, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 25, 2024	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 25, 2024	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Jan 27, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 26, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 26, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 26, 2023	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
May 26, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 26, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
May 26, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 26, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 26, 2023	D · Potential for harm, one-off	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Oct 4, 2019	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 4, 2019	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 4, 2019	E · Potential for harm, repeated	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Oct 4, 2019	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Oct 4, 2019	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Oct 4, 2019	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Oct 4, 2019	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Oct 4, 2019	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 4, 2019	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Oct 4, 2019	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Oct 4, 2019	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 4, 2019	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (8 → 3).

Year	Citations	Worst severity that year
2019	12	F
2023	8	E
2024	3	E
2025	3	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.37	4.31	3.95	bottom 6% in California; bottom 30% in the U.S.
Registered Nurse hours	0.77	0.61	0.69	top 19% in California; top 30% in the U.S.
Weekend total nurse staffing	3.05	3.90	3.50	bottom 6% in California; bottom 34% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.67	0.51	0.48	top 17% in California; top 18% in the U.S.
Total nursing staff turnover (%)	31.7	36.7	45.8	top 36% in California; top 17% in the U.S.
RN turnover (%)	42.9	38.1	42.9	bottom 39% in California; bottom 49% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.80, RN 0.87, weekend 3.44. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Providence Group INC	Organization	5% or Greater Direct Ownership Interest	100%	01/01/2019
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Portier, David	Individual	Contracted Managing Employee	NOT APPLICABLE	09/01/2019
Russell, Matthew	Individual	W-2 Managing Employee	NOT APPLICABLE	09/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Sequoias San Francisco Convalescent Hospital	0.2 mi	San Francisco, CA	★★★★☆	3/5
Victorian Post Acute	0.4 mi	San Francisco, CA	★★★★★	4/5
Pacific Heights Transitional Care Center	0.6 mi	San Francisco, CA	★★★★★	5/5
Laurel Heights Community Care	0.7 mi	San Francisco, CA	★★★★★	4/5
San Francisco Towers	0.7 mi	San Francisco, CA	★★★★★	5/5
City View Post Acute	0.7 mi	San Francisco, CA	★★☆☆☆	2/5
San Francisco Health Care	0.7 mi	San Francisco, CA	★☆☆☆☆	1/5
Hayes Convalescent Hospital	0.8 mi	San Francisco, CA	★★★★★	5/5
California Pacific Medical Ctr- Davies Campus Hosp	0.9 mi	San Francisco, CA	★★★★★	5/5
Chinese Hospital D/P SNF	1.4 mi	San Francisco, CA	★★★★☆	4/5
St. Anne's Home	1.7 mi	San Francisco, CA	★★★☆☆	4/5
Zuckerberg San Francisco General Hosp & Trauma SNF	2.1 mi	San Francisco, CA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in San Francisco →

Facility data as of CMS processing date 2026-08-01. CCN 055280.

The Care File

Visit checklist — Central Gardens Post Acute

1355 Ellis Street, San Francisco, CA 94115 · 4155672967

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055280 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)