Villa Marin
100 Thorndale Drive, San Rafael, CA 94903 · Marin County · 31 certified beds · avg 16 residents/day · certified since Jul 9, 1986
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · 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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 18, 2023 · 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: Sep 18, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (21)
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 |
|---|---|---|
| Nov 18, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Nov 18, 2025 | 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 18, 2025 | 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. |
| Nov 18, 2025 | 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. |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Apr 10, 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 |
| Aug 18, 2023 | ▲ 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 |
| Aug 18, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Aug 18, 2023 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Aug 18, 2023 | 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. |
| Aug 18, 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. |
| Aug 18, 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. |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Mar 1, 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. |
| Mar 1, 2019 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 1, 2019 | E · Potential for harm, repeated | 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. |
| Mar 1, 2019 | 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. |
| Mar 1, 2019 | 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. |
| Mar 1, 2019 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 6 | 0 | F |
| 2023 | 9 | 1 | G ▲ |
| 2024 | 1 | 0 | D |
| 2025 | 5 | 0 | F |
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) | 7.99 | 4.31 | 3.95 | top 1% in California; top 1% in the U.S. |
| Registered Nurse hours | 2.19 | 0.61 | 0.69 | top 1% in California; top 1% in the U.S. |
| Weekend total nurse staffing | 6.31 | 3.90 | 3.50 | top 2% in California; top 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.15 | 0.51 | 0.48 | top 6% in California; top 4% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 36.7 | 45.8 | — |
| RN turnover (%) | 0.0 | 38.1 | 42.9 | — |
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 7.15, RN 1.96, weekend 5.64. 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 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Havel, Milan | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/02/2016 |
| Havel, Milan | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2016 |
| Stephens, Patricia | Individual | W-2 Managing Employee | NOT APPLICABLE | 03/28/2016 |
| Walker, Daniel | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/01/2014 |
| Walker, Daniel | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "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?"
- "How do you make sure resident assessments are completed and submitted to the state on time?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "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 |
|---|---|---|---|---|---|
| Pine Ridge Care Center | 0.8 mi | San Rafael, CA | ★★★★★ | 3/5 | |
| Northgate Postacute Care | 0.8 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | abuse |
| Professional Post Acute Center | 0.8 mi | San Rafael, CA | ★★★☆☆ | 2/5 | |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 1.6 mi | San Rafael, CA | ★★★☆☆ | 2/5 | |
| Marin Post Acute | 1.6 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | abuse |
| San Rafael Healthcare & Wellness Center, LP | 2.0 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | |
| The Tamalpais | 4.1 mi | Greenbrae, CA | ★★★★★ | 4/5 | |
| South Marin Health & Wellness Center | 4.1 mi | Greenbrae, CA | ★★★★☆ | 3/5 | |
| Novato Healthcare Center | 6.7 mi | Novato, CA | ★☆☆☆☆ | 1/5 | abuse |
| The Redwoods, a Community of Seniors | 7.6 mi | Mill Valley, CA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555227.