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Victorian Post Acute
2121 Pine Street, San Francisco, CA 94115 (opens Google Maps) · San Francisco County · (415) 922-5085· 90 certified beds · avg 87 residents/day · certified since Oct 31, 1967 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
4/5
Health inspection rating (on-site)
inspected Feb 20, 2025
2
Serious findings on record
most recent Aug 23, 2019
$0
Fines, last 3 years
3.37
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
New to these records? How to read an inspection report →
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5 · how star ratings work →
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, isolated · Aug 23, 2019 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
▲ Actual harm, isolated · Aug 23, 2019 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 7, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Aug 23, 2019 · F-0745
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
▲ Actual harm, isolated · Aug 23, 2019 · F-0745
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 7, 2019 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 36 inspection findings. Open the full record below to read every finding.
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. F-0760
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. F-0880
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. · from a complaint F-0580
View all 36 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 20, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0760 |
| Feb 20, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0880 |
| Mar 8, 2024 | D · Potential for more than minimal harm, isolated | 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. · from a complaint · F-0580 |
| Mar 7, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697 |
| Apr 21, 2023 | F · Potential for more than minimal harm, widespread | 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. · F-0812 |
| Apr 21, 2023 | F · Potential for more than minimal harm, widespread | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Apr 21, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Apr 21, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · F-0813 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0582 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · F-0585 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · F-0638 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · F-0745 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0759 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0761 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0880 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. · F-0912 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · F-0925 |
| Aug 23, 2019 | ▲ G · Actual harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Aug 23, 2019 | ▲ G · Actual harm, isolated | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · F-0745 |
| Aug 23, 2019 | F · Potential for more than minimal harm, widespread | 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. · F-0732 |
| Aug 23, 2019 | F · Potential for more than minimal harm, widespread | 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. · F-0812 |
| Aug 23, 2019 | F · Potential for more than minimal harm, widespread | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. · F-0912 |
| Aug 23, 2019 | E · Potential for more than minimal harm, pattern | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · F-0623 |
| Aug 23, 2019 | E · Potential for more than minimal harm, pattern | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806 |
| Aug 23, 2019 | E · Potential for more than minimal harm, pattern | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · F-0808 |
| Aug 23, 2019 | D · Potential for more than minimal harm, isolated | 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. · F-0609 |
| Aug 23, 2019 | D · Potential for more than minimal harm, isolated | 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. · F-0657 |
| Aug 23, 2019 | D · Potential for more than minimal harm, isolated | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · F-0661 |
| Aug 23, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · F-0825 |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (20 → 2).
All citationsSerious citations (G–L)
2019
All citations: 12
Serious citations (G–L): 2
2023
All citations: 20
Serious citations (G–L): 0
2024
All citations: 2
Serious citations (G–L): 0
2025
All citations: 2
Serious citations (G–L): 0
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 12 | 2 | G ▲ |
| 2023 | 20 | 0 | F |
| 2024 | 2 | 0 | D |
| 2025 | 2 | 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)
Nurse staffing (from payroll records, adjusted for how much care residents need)
What these staffing numbers mean →
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.37
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: 0.40
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.28
California average: 3.90
U.S. average: 3.50
All bars start at zero. Exact values and supporting details remain below.
| 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 | 0.40 | 0.61 | 0.69 | bottom 33% in California; bottom 23% in the U.S. |
| Weekend total nurse staffing | 3.28 | 3.90 | 3.50 | bottom 15% in California; bottom 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.51 | 0.48 | bottom 40% in California; bottom 38% in the U.S. |
| Total nursing staff turnover (%) | 44.1 | 36.7 | 45.8 | bottom 28% in California; top 48% in the U.S. |
| RN turnover (%) | 25.0 | 38.1 | 42.9 | top 26% in California; top 20% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 3.82, RN 0.46, weekend 3.71.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.82 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Costs & payment
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Victorian Post Acute. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
- Request the room type, effective date and itemized daily rate in writing.
- Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
- Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Understand who pays for care · How we handle price evidence · Report an incorrect price
Who owns this facility
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bay Area Master Tenant LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2017 |
| Jergensen, Joshua | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2024 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Portier, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Portier, David | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/05/2021 |
| Russell, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/07/2019 |
| Russell, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 01/07/2019 |
All 10 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain Pacs Group — 274 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
- Villa Las Palmas Healthcare Center — El Cajon, CA · overall 3/5
- Vineyard Post Acute — Petaluma, CA · overall 3/5
- Visalia Post Acute — Visalia, CA · overall 1/5
- Waterman Canyon Post Acute — San Bernardino, CA · overall 4/5
- West Valley Post Acute — West Hills, CA · overall 2/5abuse
- Western Slope Health Center — Placerville, CA · overall 4/5
- Westgate Gardens Care Center — Visalia, CA · overall 3/5
- Westview Healthcare Center — Auburn, CA · overall 2/5abuse
Listed by state, then facility name — not a ranking. Showing 8 of the 273 others, continuing from this facility's own place in that list.
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 assess and manage residents' pain, especially for those who have trouble communicating?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can I see where garbage is stored and how often it's removed?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
Also worth asking anywhere
- "Your weekend nurse staffing is reported below the California midpoint — how does the weekend schedule differ from a weekday?"
- "Can I see the plan of correction for the findings in your most recent state inspection?"
- "CMS reports 44% total nursing staff turnover here — who on the care team has been with you longest?"
- "Can I visit again unannounced, at a mealtime or on a weekend?"
Nearby facilities (12 closest of 88 within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sequoias San Francisco Convalescent Hospital | 0.2 mi | San Francisco, CA | ★★★★☆ | 3/5 | |
| Central Gardens Post Acute | 0.4 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Pacific Heights Transitional Care Center | 0.6 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| San Francisco Towers | 0.6 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Laurel Heights Community Care | 0.6 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| City View Post Acute | 0.6 mi | San Francisco, CA | ★★☆☆☆ | 2/5 | |
| San Francisco Health Care | 1.0 mi | San Francisco, CA | ★☆☆☆☆ | 1/5 | |
| Hayes Convalescent Hospital | 1.1 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Chinese Hospital D/P SNF | 1.2 mi | San Francisco, CA | ★★★★☆ | 4/5 | |
| California Pacific Medical Ctr- Davies Campus Hosp | 1.3 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| St. Anne's Home | 1.6 mi | San Francisco, CA | ★★★☆☆ | 4/5 | |
| Zuckerberg San Francisco General Hosp & Trauma SNF | 2.5 mi | San Francisco, CA | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Other facilities in the same county
CMS records place this facility in San Francisco, CA — 18 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
- Jewish Home & Rehab Center D/P SNF — San Francisco, CA · overall 5/5
- Laguna Honda Hospital & Rehabilitation Ctr D/P SNF — San Francisco, CA · overall 3/5abuse
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 055848.