Laurel Heights Community Care
San Francisco, California · CCN 555869
14 surveys since 2011, 3 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 88
- Surveys
- 14
- Harm or worse
- 3
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 32
- Ownership
- For profit - Corporation
- Chain
- Independent
- County
- San Francisco
- Medicare-certified since
- 2011
CMS ratings
- Overall
- 5
- Health inspection
- 4
- Staffing
- 4
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 252 for-profit facilities with fewer than 66 beds in California.
Last survey on record
Jul 31, 2025
466 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.09 | 4.36 |
| Registered-nurse hours per resident day | 0.43 | — |
| Annual nurse turnover | 14.3% | 36.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $8,018 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G14.2% | H— | I— |
| No harm, potential for more than minimal | D1145.8% | E625.0% | F520.8% |
| No harm, potential for minimal | A— | B14.2% | C— |
Most frequently cited here
In CMS’s current monthly file.
- F9123×
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- F8032×
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5581×
Reasonably accommodate the needs and preferences of each resident.
In the surveyor’s words
From the most serious findings on record at Laurel Heights Community Care, in the surveyor’s own words.
- Actual harm, isolatedF689May 8, 2024
Based on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of four sampled residents (Resident 1) when Resident 1 fell from the mechanical lift device (also known as Hoyer lift, a device that helps caregivers lift and transfer residents from one place to another) while being transferred by Certified Nursing Assistant (CNA) 1 from his bed to recliner. This failure resulted in Resident 1 sustaining a head trauma (injury that occurs when there is a direct or indirect blow to the head), which led to hospitalization and subsequent death. Findings: Review of the facility's investigative report, dated [DATE], indicated On Friday, [DATE], at approximately 9:59 AM. […]
- No harm, potential for more than minimal, widespreadF801Apr 19, 2024
Based on observation, staff interviews, and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. 2. […]
- No harm, potential for more than minimal, widespreadF802Apr 19, 2024
Based on observation, interview, and facility document review, the facility failed to ensure kitchen staff competency for: 1. Calibrating food thermometers; 2. Cooldown procedures for Time/Temperature Control for Safety (TCS) food (food which requires time and temperature monitoring to prevent the growth of harmful bacteria); 3. Procedures for monitoring dishmachine temperature and sanitizer strength; 4. Temperature monitoring for trayline food; 5. Temperature monitoring for food storage coolers; 6. Manual dishwashing using the two-compartment sink; and 7. […]
- No harm, potential for more than minimal, widespreadF803Apr 19, 2024
Based on observation, interview, and facility document review, the facility failed to follow the planned menu. This failure had the potential to result in inadequate and/or inappropriate nutrients served to residents leading to nutrient related medical complications for 27 residents who received food from the kitchen. Findings: Review of the facility's policy and procedure titled Food Preparation Portion Control dated 2018, showed to be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. […]
- No harm, potential for more than minimal, widespreadF804Apr 19, 2024
Based on observation, interview, and facility document review, the facility failed to serve food that was flavorful and at a palatable temperature. This failure had the potential for decreased food intake leading to nutrient related complications for 27 residents who received food from the kitchen. Findings: Review of the facility policy and procedure titled Meal Service dated 2018, showed the Food and Nutrition Services staff member will take the food temperature prior to service of the meal with a thermometer. It may be necessary to take the temperature in more than one location on the food item to confirm the proper temperature has been reached. The food temperatures will be recorded. […]
Read 22 findings in full →The most serious and the most recent: 22 of 88 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 31, 2025Standard4 findings
- May 8, 2024Complaint1 finding · 1 harm
- Apr 19, 2024Standard16 findings
- Dec 9, 2021Standard3 findings
- Jun 21, 2019Standard1 finding
- Jul 13, 2018Standard4 findings
- Jun 1, 2017Standard7 findings
- Apr 7, 2016Standard7 findings
Show the 6 earlier surveys
- Mar 2, 2015Standard9 findings
- Jul 2, 2014Complaint1 finding · 1 harm
- Mar 28, 2014Standard10 findings
- Mar 29, 2013—6 findings
- Apr 18, 2012—8 findings
- Mar 4, 2011—11 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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