Pacific Heights Transitional Care Center

Name: Pacific Heights Transitional Care Center
Address: 2707 PINE STREET, San Francisco, CA, 94115, US
Telephone: 4155637600

2707 Pine Street, San Francisco, CA 94115 · San Francisco County · 120 certified beds · avg 115 residents/day · certified since Mar 29, 1974

Part of chain: ASPEN SKILLED HEALTHCARE (35 facilities, chain avg rating 3.7★)

5/5

Health inspection rating (on-site)

Serious findings on record

$25,490

Fines, last 3 years

4.18

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 (25)

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
Mar 13, 2026	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Mar 13, 2026	E · Potential for harm, repeated	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.
Mar 13, 2026	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Mar 13, 2026	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.
Jan 29, 2025	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
Aug 29, 2024	E · Potential for harm, repeated	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Aug 29, 2024	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 29, 2024	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.
Aug 29, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Aug 29, 2024	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.
Aug 29, 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.
Aug 29, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Aug 29, 2024	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Aug 29, 2024	D · Potential for harm, one-off	The facility did not provide timely, quality laboratory tests to meet residents' needs.
Aug 29, 2024	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.
Aug 29, 2024	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Sep 12, 2023	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Apr 28, 2021	F · Potential for harm, facility-wide	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 28, 2021	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 28, 2021	E · Potential for harm, repeated	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 28, 2021	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.
Apr 28, 2021	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.
Apr 28, 2021	E · Potential for harm, repeated	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.
Apr 28, 2021	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.
Apr 28, 2021	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.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (11 → 4).

Year	Citations	Worst severity that year
2021	8	F
2023	1	D
2024	11	E
2025	1	D
2026	4	E

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)

1 fine totaling $25,490.

Date	Type	Amount / length
Jan 29, 2025	Fine	$25,490

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)	4.18	4.31	3.95	top 46% in California; top 33% in the U.S.
Registered Nurse hours	0.84	0.61	0.69	top 16% in California; top 25% in the U.S.
Weekend total nurse staffing	3.82	3.90	3.50	top 45% in California; top 29% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.60	0.51	0.48	top 22% in California; top 23% in the U.S.
Total nursing staff turnover (%)	42.0	36.7	45.8	bottom 33% in California; top 42% in the U.S.
RN turnover (%)	45.8	38.1	42.9	bottom 33% in California; bottom 42% 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 4.09, RN 0.82, weekend 3.74. Staffing rating: 4/5.

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: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Asfp, LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	12/20/2018
Bradshaw, Peter	Individual	Indirect Ownership Interest	NOT APPLICABLE	07/07/2023
Elsner, Eric	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Parti, Shruty	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Paxman, Marcus	Individual	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Sequoia Healthcare Group LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
SKBM LLC	Organization	5% or Greater Direct Ownership Interest	100%	09/01/2017
Aquino, Jocelyn	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2017
Aquino, Jocelyn	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2017
Asfp, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	12/20/2018
Aspen Healthcare Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2023
Bradshaw, Jeffrey	Individual	Corporate Director	NOT APPLICABLE	09/01/2017
Bradshaw, Jeffrey	Individual	Corporate Officer	NOT APPLICABLE	09/01/2017
Bradshaw, Jeffrey	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2017
Bradshaw, Jeffrey	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/29/2026
Brady, Vern	Individual	Corporate Director	NOT APPLICABLE	09/01/2017
Brady, Vern	Individual	Corporate Officer	NOT APPLICABLE	09/01/2017
Case, Ryan	Individual	Corporate Director	NOT APPLICABLE	09/01/2017
Case, Ryan	Individual	Corporate Officer	NOT APPLICABLE	09/01/2017
Gerding, Goeffrey	Individual	Operational/Managerial Control	NOT APPLICABLE	02/17/2020

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 often do you evaluate your nurse aides and what ongoing training do they receive?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you coordinate and monitor care for residents who receive dialysis?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"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
Laurel Heights Community Care	0.1 mi	San Francisco, CA	★★★★★	4/5
Victorian Post Acute	0.6 mi	San Francisco, CA	★★★★★	4/5
Sequoias San Francisco Convalescent Hospital	0.6 mi	San Francisco, CA	★★★★☆	3/5
Central Gardens Post Acute	0.6 mi	San Francisco, CA	★★★★★	5/5
San Francisco Health Care	0.8 mi	San Francisco, CA	★☆☆☆☆	1/5
Hayes Convalescent Hospital	0.8 mi	San Francisco, CA	★★★★★	5/5
St. Anne's Home	1.1 mi	San Francisco, CA	★★★☆☆	4/5
San Francisco Towers	1.1 mi	San Francisco, CA	★★★★★	5/5
City View Post Acute	1.1 mi	San Francisco, CA	★★☆☆☆	2/5
California Pacific Medical Ctr- Davies Campus Hosp	1.4 mi	San Francisco, CA	★★★★★	5/5
Chinese Hospital D/P SNF	1.7 mi	San Francisco, CA	★★★★☆	4/5
Lawton Skilled Nursing & Rehabilitation Center	2.2 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 056176.

The Care File

Visit checklist — Pacific Heights Transitional Care Center

2707 Pine Street, San Francisco, CA 94115 · 4155637600

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $25,490

Questions for the administrator:

☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you coordinate and monitor care for residents who receive dialysis?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "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 056176 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)