Inspection Reports for AlmaVia of San Francisco
1 Thomas More Way, San Francisco, CA 94132, United States, CA, 94132
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining compliance in areas like medication storage, cleanliness, and staff training. However, some complaint investigations were substantiated, including improper resident restraint with a gait belt in August 2025 and failure to provide proper notice of rate increases in April 2025. There was also a substantiated incident in October 2024 where a resident with dementia eloped due to staff sleeping during overnight hours, posing an immediate safety risk. The most recent report from October 7, 2025, was clean with no deficiencies cited, indicating improvement after earlier issues. Several other complaint investigations were unsubstantiated, and no fines or license actions were listed in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
73% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 127
Capacity: 175
Deficiencies: 0
Date: Oct 7, 2025
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements and ensure the safety and well-being of residents.
Findings
The facility was found to be generally compliant with regulations, including proper medication storage, clean kitchen and laundry areas, functional emergency equipment, and current staff and resident files. No citations were issued during this inspection.
Report Facts
Residents under hospice care: 9
Hospice waiver capacity: 35
Water temperature: 105
Water temperature: 110
Emergency/disaster drill date: Sep 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 128
Capacity: 175
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
The visit was an unannounced case management-incident inspection regarding a report (SOC 341) submitted by the facility about a resident being restrained improperly with a gait belt.
Findings
The inspection found that two staff members restrained a resident with a gait belt, limiting the resident's hands, which posed an immediate health, safety, and personal rights risk. The facility terminated the two staff members and conducted in-service training on restraint risks and reporting requirements.
Deficiencies (1)
Two staff members restrained a resident with a gait belt limiting the use of the resident's hands, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 175
Census: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during inspection and mentioned staffing overlap |
| Grace Donato | Licensing Program Analyst | Conducted the unannounced case management-incident inspection |
Inspection Report
Census: 129
Capacity: 175
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The visit was a Case Management visit to deliver an Amended report related to a previously delivered report from 4/30/2024. The complaint was reopened due to additional information received by the Department.
Complaint Details
This complaint was reopened due to additional information received by the Department. A new finding was delivered on 4/17/2025.
Findings
During the visit, the Licensing Program Analyst reviewed the amended report with the Administrator and provided a copy of the report. A new finding was delivered to the Licensee on 4/17/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the Case Management visit and reviewed the amended report with the Administrator. |
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during the visit and received the amended report. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The visit was an unannounced case management inspection to address a complaint investigation regarding improper notice of rate increases to a resident.
Complaint Details
The complaint was substantiated and involved allegations that facility staff did not provide proper notice of rate increase for resident R1, with inconsistencies found in invoices, payment ledgers, and rate increase notices dated 7/31/2020 and 4/30/2021.
Findings
The facility failed to provide proper notice of rate increases that included modification conditions and rate structure changes as required, resulting in inconsistencies between notices and payment ledgers for resident R1. This deficiency poses a potential health, safety, and personal rights risk to the resident.
Deficiencies (1)
Failure to provide proper notice of rate increase that identifies modification conditions and rate structure changes as required by 87507(g)(4) Admissions Agreements.
Report Facts
Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during the inspection |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and signed the report |
| Andrea Medlin | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 134
Capacity: 175
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
The visit was an unannounced case management visit to discuss and request resident records based on additional findings from a Licensing Program Analyst's review of investigation evidence.
Findings
No deficiencies were cited during the visit. An amendment to the original report removed a previously cited deficiency, and no citation was issued.
Deficiencies (1)
LPA did not determine a deficiency during visit. Citation removed. No citation issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during the visit. |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection visit and created the report. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to complaints alleging that prior to admission staff did not provide resident or resident's authorized person with an appraisal of the resident's individual service needs and that staff did not provide records to resident or resident's authorized person upon request.
Complaint Details
Complaint investigation was unsubstantiated due to inconsistent information and lack of corroborating evidence regarding allegations about appraisal of service needs and provision of records. No deficiencies were cited.
Findings
The investigation found that the facility had completed an appraisal prior to admission and the resident expressed satisfaction with care. Interviews revealed inconsistent information and lack of corroborating evidence, resulting in all allegations being unsubstantiated with no deficiencies cited.
Report Facts
Facility capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Cleitus Jones | Executive Director | Met with investigator during complaint investigation |
| Andrea Medlin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff did not provide proper notice of rate increase for a resident.
Complaint Details
Complaint alleges facility staff did not provide proper notice of rate increase for resident (R1). The allegation was substantiated based on evidence that notices did not match fees charged and lacked clear indication of modifications and rate structures.
Findings
The complaint was substantiated. The investigation found inconsistencies between the rate increase notices and the actual fees charged, including failure to clearly indicate modified conditions and rate structures in the notices and invoices.
Deficiencies (1)
Failure to provide proper notice of rate increase as required by Title 22 Regulations, Division 6.
Report Facts
Facility capacity: 175
Monthly rate: 4885
Monthly rate: 5595
Monthly rate: 5700
Monthly fee discount: 710
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with during investigation and mentioned in findings |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Medlin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 175
Deficiencies: 2
Date: Oct 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation of lack of supervision resulting in a resident eloping from the facility.
Complaint Details
The complaint was substantiated. Resident (R1) eloped from the facility on 9/28/2024 during overnight hours due to lack of supervision by staff (S1) who was asleep. R1 has dementia and wandering behavior and is not allowed to leave unassisted.
Findings
The complaint was substantiated as it was found that a resident with dementia eloped from the facility during overnight hours because staff was asleep and failed to properly supervise. Deficiencies related to personnel requirements were cited and corrective actions were implemented.
Deficiencies (2)
Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Administrator failed to prevent resident (R1) from eloping the facility.
Staff (S1) was asleep during the incident and not properly supervised resident (R1), who is diagnosed with dementia and at wander risk, creating an immediate health and safety risk.
Report Facts
Capacity: 175
Census: 136
Plan of Correction Due Date: Oct 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with during investigation and named in findings related to supervision failure |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Medlin | Licensing Program Manager | Oversaw licensing program and cited deficiencies |
Inspection Report
Annual Inspection
Census: 136
Capacity: 175
Deficiencies: 1
Date: Oct 11, 2024
Visit Reason
The inspection was an unannounced annual required one-year inspection to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was found to be clean, well-maintained, and compliant with fire safety and food storage regulations. Resident care plans and staff training were mostly up to date, except for one staff member lacking a health screening report. No deficiencies were cited during the visit.
Deficiencies (1)
Staff member (S1) does not have health screening report on file.
Report Facts
Residents receiving hospice services: 12
Fire extinguisher last inspection date: Jul 15, 2024
Fire safety inspection date: Jul 3, 2024
Last emergency drill date: Sep 28, 2024
Administrator certificate expiration: Apr 4, 2026
Document submission deadline: Oct 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met during inspection and named in relation to facility administration |
| Ping Huang | Plant Operations Director | Met during inspection and named in relation to facility operations |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 175
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a resident sustained injuries due to staff neglect and that staff did not ensure the facility transport vehicle was not in disrepair.
Complaint Details
The complaint alleged that a resident sustained injuries due to staff neglect and that staff failed to ensure the facility transport vehicle was not in disrepair. The investigation concluded both allegations were unsubstantiated.
Findings
The investigation found that the resident's minor injury was not due to staff neglect as proper manual transportation protocols were followed, and although the facility vehicle's wheelchair lift was not electronically operational, it was equipped with a manual crank allowing proper function. Both allegations were found to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Complaint Control Number: 14-AS-20240823163924
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during investigation and provided information regarding the complaint. |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Andrea Medlin | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 175
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
The visit was an unannounced case management and incident follow-up related to a complaint investigation involving a resident injury during transport on 08/22/2024.
Complaint Details
The visit was complaint-related, investigating an incident where resident R1 was injured during transport due to wheelchair lift malfunction and inadequate accommodations. The injury was minor and not due to intent or neglect, but staff did not ensure safe equipment or additional support.
Findings
The facility failed to ensure safe accommodations and equipment for resident R1, who sustained a minor injury after falling from a wheelchair lift during transport. The wheelchair lift's manual crank caused a jerking motion contributing to the fall, and the resident's wheelchair type provided less stability.
Deficiencies (1)
Failure to provide safe, healthful, and comfortable accommodations and equipment, resulting in resident injury from falling off wheelchair lift during transport.
Report Facts
Census: 134
Total Capacity: 175
Plan of Correction Due Date: Due date for correcting deficiency is 09/27/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleitus Jones | Executive Director | Met with Licensing Program Analyst during inspection and mentioned in deficiency findings |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and signed the report |
| Andrea Medlin | Licensing Program Manager | Supervisor overseeing the inspection and deficiency citation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 175
Deficiencies: 0
Date: Apr 10, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility refused to take a resident back after hospital discharge.
Complaint Details
The complaint alleged that the facility refused to take resident #1 back after hospital discharge. The allegation was investigated and found to be unfounded.
Findings
The investigation found the allegation to be unfounded as the resident was assessed by the administrator at the hospital and returned to the facility with hospital discharge instructions. The resident is currently under home health care for wound treatment.
Report Facts
Facility capacity: 175
Resident census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Reviewed the complaint investigation report |
| Adriana Garcia | Memory Care Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Alan Fox | Administrator | Assessed resident at hospital and involved in resident's return to facility |
Inspection Report
Annual Inspection
Census: 118
Capacity: 175
Deficiencies: 0
Date: Oct 10, 2022
Visit Reason
An unannounced annual inspection was conducted to review compliance with licensing requirements, including infection control and facility safety.
Findings
The facility was found to be clean and tidy with appropriate storage of toxins and sharps, proper infection control signage, and adequate safety measures. No deficiencies were cited during this inspection.
Report Facts
Refrigerator temperature: 38
Freezer temperature: -10
Hand washing sinks: 3
Capacity: 175
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alan Fox | Administrator | Met with Licensing Program Analyst during inspection |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
| Cara Smith | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 175
Deficiencies: 1
Date: Sep 22, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2022-08-11 alleging that staff were not allowing residents to leave the facility.
Complaint Details
The complaint was substantiated. The allegation was that staff did not allow residents R1 and R2 to leave the facility. The investigation found that staff incorrectly interpreted the Durable Power of Attorney documents and prevented the residents from leaving, violating residents' rights.
Findings
The investigation substantiated the allegation that the facility staff prevented residents R1 and R2 from leaving the facility, violating Title 22 Division 6 Section 87468.1 regarding residents' personal rights to leave the facility at any time. The facility acknowledged the misunderstanding and reported that the residents have since returned home.
Deficiencies (1)
Facility staff prevented residents R1 and R2 from leaving the facility, violating CCR 87468.1 Personal Rights of Residents.
Report Facts
Capacity: 175
Census: 116
Plan of Correction Due Date: Oct 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alan Fox | Administrator | Met with during investigation and involved in findings regarding resident discharge |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 175
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident sustained a stage 3 pressure ulcer while in care.
Complaint Details
The complaint alleged that a resident sustained a stage 3 pressure ulcer while in care. The investigation included interviews and record reviews, concluding that the allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation to be unsubstantiated as the facility took appropriate preventive and treatment actions for the resident's pressure ulcer, but the ulcer developed due to the resident's health condition.
Report Facts
Facility capacity: 175
Resident census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alan Fox | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 101
Capacity: 175
Deficiencies: 0
Date: Oct 22, 2021
Visit Reason
An unannounced annual inspection was conducted to review compliance with infection control and COVID-19 protocols, including document review and facility tour.
Findings
The facility was found to be in compliance with infection control measures, including adequate PPE supplies, proper signage, and social distancing. Recommendations were made for additional COVID-19 signage and enhanced cleaning protocols for a public phone.
Report Facts
Capacity: 175
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alan Fox | Administrator | Met with Licensing Program Analyst during inspection |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
| Julio Montes | Licensing Program Manager | Named in report header |
Inspection Report
Census: 104
Capacity: 175
Deficiencies: 0
Date: Apr 20, 2021
Visit Reason
The inspection was an unannounced Case Management Inspection conducted in response to an incident reported by the facility on 4/15/2021, involving a resident who was bumped on the head by a falling lamp.
Findings
The Licensing Program Analyst conducted the inspection remotely due to the pandemic, reviewed relevant documents including physician reports and service plans, and discussed the report with the Executive Director. The report was to be signed and returned with requested documents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benito Del Toro | Executive Director | Met with Licensing Program Analyst regarding the incident and inspection. |
Inspection Report
Census: 99
Capacity: 175
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
An unannounced Case Management Inspection was conducted due to concerns reported to the San Bruno Regional Office regarding the facility's COVID-19 protocols.
Findings
The Licensing Program Analyst requested the facility's roster and COVID-19 updates from the Executive Director, Benito Del Toro, who agreed to provide the reports by 03/03/2021. The report was reviewed with the Administrator and provided for signature.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benito Del Toro | Executive Director | Spoke with Licensing Program Analyst during inspection and provided requested documents. |
Viewing
Loading inspection reports...
