Laguna Honda Hospital & Rehabilitation Ctr D/P SNF
375 Laguna Honda Blvd., San Francisco, CA 94116 · San Francisco County · 769 certified beds · avg 590 residents/day · certified since May 30, 2024
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 1, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 27, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 3, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 19, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 28, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2024 · F-0656 · triggered by a complaint
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.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (40)
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 |
|---|---|---|
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 1, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 4, 2025 | D · Potential for harm, one-off | 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 |
| May 2, 2025 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| May 2, 2025 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| May 2, 2025 | 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. |
| May 2, 2025 | 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 2, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 2, 2025 | 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 2, 2025 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| May 2, 2025 | D · Potential for harm, one-off | 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. |
| Nov 8, 2024 | 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. |
| Nov 8, 2024 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Nov 8, 2024 | 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. |
| Nov 8, 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. |
| Nov 8, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Nov 8, 2024 | 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. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| May 3, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 19, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | 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 |
| Feb 28, 2024 | ▲ G · Actual 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. · from a complaint |
| Feb 9, 2024 | ▲ G · Actual 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. · from a complaint |
| Feb 9, 2024 | ▲ G · Actual 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 |
| Dec 1, 2023 | E · Potential for harm, repeated | 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. · from a complaint |
| Dec 1, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 1, 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. · from a complaint |
| Dec 1, 2023 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Dec 1, 2023 | D · Potential for harm, one-off | 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 |
| Dec 1, 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. |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 1, 2023 | 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. |
| Dec 1, 2023 | 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. |
| Dec 1, 2023 | 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. |
| Dec 1, 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. |
| Dec 1, 2023 | D · Potential for harm, one-off | 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. |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 0 | E |
| 2024 | 13 | 5 | G ▲ |
| 2025 | 11 | 1 | G ▲ |
| 2026 | 1 | 0 | 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)
8 fines totaling $55,499.
| Date | Type | Amount / length |
|---|---|---|
| Aug 1, 2025 | Fine | $17,323 |
| Feb 20, 2024 | Fine | $4,938 |
| Feb 12, 2024 | Fine | $4,938 |
| Jan 22, 2024 | Fine | $12,534 |
| Jan 8, 2024 | Fine | $3,418 |
| Jan 2, 2024 | Fine | $2,823 |
| Dec 11, 2023 | Fine | $6,351 |
| Nov 6, 2023 | Fine | $3,174 |
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) | 6.02 | 4.31 | 3.95 | top 5% in California; top 4% in the U.S. |
| Registered Nurse hours | 2.14 | 0.61 | 0.69 | top 1% in California; top 1% in the U.S. |
| Weekend total nurse staffing | 4.69 | 3.90 | 3.50 | top 11% in California; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.18 | 0.51 | 0.48 | top 6% in California; top 4% in the U.S. |
| Total nursing staff turnover (%) | 17.3 | 36.7 | 45.8 | top 4% in California; top 2% in the U.S. |
| RN turnover (%) | 20.2 | 38.1 | 42.9 | top 22% in California; top 16% 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 5.83, RN 2.08, weekend 4.54. Staffing rating: 5/5.
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: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| City & County of San Francisco | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1966 |
| Arnold, Timothy | Individual | Corporate Director | NOT APPLICABLE | 08/01/2023 |
| Arnold, Timothy | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Carton-Wade, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2023 |
| Carton-Wade, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Drew, Jeffrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| Drew, Jeffrey | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| Istvan, Thomas | Individual | Corporate Director | NOT APPLICABLE | 08/01/2023 |
| Istvan, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Lam, Albert | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/16/2024 |
| Lam, Albert | Individual | ADP of the SNF | NOT APPLICABLE | 01/16/2024 |
| Sidhu, Diltar | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2023 |
| Sidhu, Diltar | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Talai, Nawzaneen | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2023 |
| Talai, Nawzaneen | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can I see where garbage is stored and how often it's removed?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "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 | Flags |
|---|---|---|---|---|---|
| Lawton Skilled Nursing & Rehabilitation Center | 0.8 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| The Avenues Transitional Care Center | 1.1 mi | San Francisco, CA | ★★★★★ | 3/5 | |
| Jewish Home & Rehab Center D/P SNF | 2.1 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| Hayes Convalescent Hospital | 2.2 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| California Pacific Medical Ctr- Davies Campus Hosp | 2.2 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| San Francisco Health Care | 2.3 mi | San Francisco, CA | ★☆☆☆☆ | 1/5 | |
| San Francisco Post Acute | 2.6 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| St. Anne's Home | 2.7 mi | San Francisco, CA | ★★★☆☆ | 4/5 | |
| Zuckerberg San Francisco General Hosp & Trauma SNF | 2.8 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Central Gardens Post Acute | 3.0 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Pacific Heights Transitional Care Center | 3.0 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Laurel Heights Community Care | 3.0 mi | San Francisco, CA | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555929.