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Nursing HomeMedicaid Top Rated

The Avenues Transitional Care Center

Strong Medicare quality ratings; families often praise compassionate frontline caregivers. Still worth an in-person visit.

2043 19th Avenue, Sunset District · San Francisco, CA 94116140 bedsLicensed & Active
5/5
Medicare
Inspection
Quality
Staffing
Google rating
4.5/5

based on 28 Google reviews

5
4
3
2
1
The Avenues Transitional Care Center Nursing Home in San Francisco, CA — Street View
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What this means for your family

This facility offers a beautiful environment and exceptional frontline caregivers who treat residents like family. However, families should be cautious regarding management and nursing coordination, as multiple reviewers have reported significant difficulties in managing care as a resident's needs increase.

Google Reviews

Google Reviews

28 reviews on Google
Families often praise the facility for its beautiful, clean environment and the compassionate, family-like treatment provided by frontline caregivers. However, significant concerns exist regarding management responsiveness and the difficulty of coordinating care for residents with increasing medical needs.

Quality Themes

Tap a score for details
Food5.0Staff7.0Clean8.0Activities5.0MedsN/AMemory5.0Comms3.0Value2.0

Strengths

  • Compassionate frontline caregivers
  • Beautiful and clean environment
  • High-quality dining options
  • Smooth transition/move-in assistance

Concerns

  • Difficulties with management and nursing coordination (mentioned by 2 reviewers)
  • Staffing shortages affecting hygiene and care

Rating Trends

Tap a year to see what changed

234'17(4)'20(1)'22(1)'24(4)'26(2)

Distribution · 30 analyzed

5
22
4
3
3
3
2
0
1
2

How They Respond to Reviews

79%response rate
Good

The owner uses highly templated responses for simple star ratings but provides personalized, empathetic, and professional replies to reviews containing text. They demonstrate a strong commitment to addressing negative feedback by offering direct contact information and expressing a desire to resolve issues.

Questions for Your Tour

  • 1We've heard wonderful things about the compassion of your frontline caregivers; how do you ensure that this level of care remains consistent across all shifts?
  • 2Since the move-in process is known for being so smooth here, what kind of support can we expect to help our loved one settle into their new room?
  • 3How does the nursing team coordinate with the management team to ensure that medical updates and care plan changes are communicated clearly to families?
  • 4We noticed the dining options are a highlight for many residents; could you tell us more about how much input residents have in their daily meal choices?
  • 5In the event of a medical emergency during the night, what is the specific protocol for notifying the family and coordinating immediate care?
  • 6What kind of daily activities or social outings are planned to help residents stay engaged and connected with one another?

Personalized based on this facility's data


Key Review Excerpts

The team at Ivy Golden Gate went above and beyond for my client, treating them like family. Suzanne, the sales director, even went to their home to help pack and transfer medications - a level of service you don't always come accross.

Senior living industry professional · 2025★★★★★

The individual caregivers were wonderful, but management, the nurses, and med techs were impossible to work with.

Friend of a former resident · 2025☆☆☆☆

Since we have moved our family member into this facility in 2018/2019, it has been a nightmare trying to coordinate her care or have the appropriate supportive services that we had hoped she would be provided

Family member of a resident · 2023☆☆☆☆
Source: 28 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.89hrs
OK
Registered nurses for medical care
Total Nursing
3.98hrs
97%
All nurses + aides combined
Staff Turnover
43%
Lower is better (< 30% = good)
RN Turnover
20%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

14

measures

Mixed Results

3

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility3.9%
Mixed vs Avgs
Here
3.9%
US
19.5%
CA
13.7%
San francisco
3.7%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.1%
Better than Avg
Here
7.1%
US
14.4%
CA
10.4%
San francisco
12.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
San francisco
95.6%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility9.3%
Better than Avg
Here
9.3%
US
15.4%
CA
11.6%
San francisco
9.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility9.1%
Mixed vs Avgs
Here
9.1%
US
12.1%
CA
7.0%
San francisco
3.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility10.5%
Better than Avg
Here
10.5%
US
15.3%
CA
10.5%
San francisco
14.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility98.4%
Better than Avg
Here
98.4%
US
79.7%
CA
93.2%
San francisco
93.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.9%
Better than Avg
Here
99.9%
US
81.8%
CA
94.2%
San francisco
88.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.9%
Better than Avg
Here
0.9%
US
1.6%
CA
1.5%
San francisco
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
1penalties
Near state avg (15.4)
3 complaint-triggered
$12,685 in fines

This facility has a concerning pattern with 48 deficiencies across six surveys, including three complaint-triggered inspections where families reported problems with accident prevention and care planning. The most recurring issues involve fire safety systems, medication management, and building safety compliance. While all deficiencies show correction dates, the repeated violations across multiple surveys in the same areas (particularly fire safety equipment and building codes) suggest ongoing compliance challenges that families should discuss during visits.

Oct 2, 2025Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 24, 2025Routine
21
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0039Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0712Minimal · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0912Minimal · Pattern

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

May 21, 2024Complaint
2
0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Jan 26, 2024Routine
12
0035Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide family notifications of emergency plan.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0345Potential for harm · PatternCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0031Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Apr 5, 2023Routine
2
0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Apr 9, 2021Routine
10
0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0918Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0693Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0225Potential for harm · IsolatedCorrected

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0912Minimal · Widespread

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Federal Penalties

Fine

Oct 2, 2025

$12,685

Ownership & Operations

Who Operates This Facility

Owner / Operator

The Avenues Transitional Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

Aspen Skilled Healthcare

Chain Size

35 facilities nationwide

Chain avg rating: 3.5/5 · Rank 19 of 34

Ownership & Management

Owners

Asjk LLC

Owner · Organization

Aspen Skilled Healthcare INC

Owner (parent company) · Organization

Sequoia Healthcare Group LLC

Owner (parent company) · Organization

Skbm II LLC

Owner (parent company) · Organization

Skbm LLC

Owner (parent company) · Organization

Bradshaw, Jeffrey

Owner (parent company)

Bradshaw, Peter

Owner (parent company)

Brady, Vern

Owner (parent company)

Case, Ryan

Owner (parent company)

Elsner, Eric

Owner (parent company)

Kirkwood, Jared

Owner (parent company)

Orgill, Craig

Owner (parent company)

Parti, Rajesh

Owner (parent company)

Parti, Shruty

Owner (parent company)

Paxman, Marcus

Owner (parent company)

Bradshaw, Jeffrey

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Rawe, ColtonManaging Control - Governing BodyAsjk LLCManagerBasa, EdilManagerBradshaw, JeffreyManagerCase, RyanManager
Source: Medicare provider data

Contact

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References & Resources

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