Overall sentiment is highly mixed and polarized: many reviewers praise individual caregivers, nursing staff, and the rehabilitation program, while others report serious safety, cleanliness, and management failures. Positive reports emphasize caring and dedicated staff who provide responsive nursing care, strong physical therapy outcomes, engaging activities, and supportive family communication in some cases. Negative reports focus on systemic facility problems — pests, mold, plumbing and structural deterioration — and on lapses in clinical safety, reporting, and daily care.
Care quality and clinical oversight show a wide range. Several reviews describe excellent nursing attention, med tech responsiveness, and therapists who helped residents regain mobility — reviewers who used the facility for rehab often report rapid improvement and recommend it for short-term therapy. Conversely, multiple accounts allege neglect: missed showers and bed changes, delayed cleaning of spills, slow/incorrect laundry returns, inconsistent medication or feeding claims, and serious resident injuries (broken hip, fractured leg, infected ulcer) that families say were not communicated. There are also reports of a distant medical presence and limited physician visits, which compounds concerns when adverse events occur.
Staffing and staff behavior are recurring themes with contradictory experiences. Numerous reviewers single out individual employees (Kim is repeatedly named) and describe warm, compassionate, and hardworking staff who go beyond their duties and keep families informed. At the same time, other reviewers describe high staff turnover, unfriendly or unprofessional caregivers (especially in the memory unit), yelling at residents, wandering incidents, and nonchalant responses to theft. This inconsistency suggests uneven training, supervision, or morale — some shifts or units are praised while others are flagged for poor behavior and safety lapses.
Facility condition and cleanliness are major negative patterns. Many reviewers describe a run-down environment: roach and fly infestations, moldy ceilings, broken or unsafe fixtures (torn curtains, unsafe outlets), gross bathrooms, and rooms that do not match advertised photos. Plumbing problems and poor general maintenance are repeatedly mentioned. These physical deficiencies are tied to infection risk and general resident discomfort in several reports. A minority of reviewers note that parts of the facility have been recently redone and that some rooms are furnished and comfortable, reinforcing the mixed experience narrative.
Communication, administration, and operations receive frequent criticism. Families report very poor central phone access and long hold times, confusing or incorrect information during hospital transitions, and problems with POA/consent handling. Some reviewers credit a new administrator or other management staff with being helpful, but others point to budget constraints, hopes for new ownership, or a facility name change (to Pelican's Point) as signs of instability. At least one reviewer said the state attempted to close a case, and there are reports of regulatory scrutiny implied by severe neglect allegations.
Dining, activities, and social programming are described positively by many: good meals with large portions and dessert (by some accounts), numerous activities and parties, and an active event planner who communicates with families. These aspects contribute to positive rehab and long-term stay experiences for residents who receive consistent, caring staffing. However, conflicting complaints about underfeeding and poor cleanliness in dining/bathroom areas mean food and mealtime quality may also vary by unit or shift.
Safety is the single most serious concern raised. Reports of untreated or unreported injuries, wandering incidents, and inadequate supervision for non-ambulatory residents led some reviewers to assert that the facility is unsafe for people with high care needs or limited mobility/communication. Theft from resident rooms and perceived staff indifference elevate concerns about resident security and organizational oversight.
In summary, San Rafael Nursing and Rehabilitation Center presents as a facility with real strengths in individual caregivers and rehabilitation outcomes, but with systemic issues in maintenance, infection control, staffing consistency, communication, and safety. Prospective families and referral sources should consider these patterns: the facility may be suitable for short-term rehab when the praised therapy and nursing teams are in place, but families of long-term or high-dependency residents should investigate current staffing levels, pest control and maintenance status, incident reporting practices, and how the facility handles physician coverage. Repeated mentions of a new administrator and hopes for new ownership suggest potential improvement, but the breadth of negative operational issues indicates the need for caution and thorough, recent verification before placement.
