
Report
TheVardellReport
San Rafael Healthcare & Wellness Center, LP
Skilled nursing facility and nursing facility
1601 5Th Avenue
San Rafael, CA 94901

TheVardellReport
Skilled nursing facility and nursing facility
1601 5Th Avenue
San Rafael, CA 94901
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 18 inspections from January 2020 to August 2026, state surveyors documented 55 findings at San Rafael Healthcare & Wellness Center, LP; 55 have a recorded correction; CMS lists 2 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2020 | 1 | 4 | 0 |
| 2021 | 0 | 0 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 2 | 13 | 0 |
| 2024 | 2 | 2 | 0 |
| 2025 | 10 | 33 | 1 |
| 2026 | 3 | 3 | 0 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
18 findings
Enforcement Action
Civil money penalty, $8,278 imposed March 20, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 20, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed March 20, 2025. Status: Closed, May 19, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 20, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
12 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F689 in February 2025, March 2025, December 2025 and June 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in January 2020, May 2023, March 2025 and June 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F656 in May 2023, February 2025 and March 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in January 2020, May 2023 and March 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F550 in July 2026 and August 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F552 in May 2023 and April 2025. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F558 in May 2023 and March 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F559 in February 2025 and March 2025. The agency describes it this way: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F600 in November 2023 and July 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F623 in March 2025 and March 2025. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F641 in May 2023 and March 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F658 in March 2025 and June 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F726 in May 2024 and March 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F921 in May 2023 and March 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level G.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level F.
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level D.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in two inspections, most seriously at level E.
What changed after F552 was cited, and how do you check it now?
Citation F552: cited in two inspections, most seriously at level E.
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in two inspections, most seriously at level D.
What changed after F559 was cited, and how do you check it now?
Citation F559: cited in two inspections, most seriously at level D.
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.
When do you transfer or discharge a resident, and how much notice do families get?
Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in two inspections, most seriously at level E.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in two inspections, most seriously at level D.
What changed after F921 was cited, and how do you check it now?
Citation F921: cited in two inspections, most seriously at level D.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2025 fine, and has it been paid?
An $8,278 civil money penalty was imposed March 20, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
California state survey agency
Inspection Jan 17, 2020 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection May 25, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Nov 7, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection May 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection May 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jun 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jun 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 1, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 055331
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowJanuary 17, 2020 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.