Madrona Hospice Care Inc.
A hospice in San Rafael, California 94903
185 N Redwood Dr, Suite 110, San Rafael, California 94903. (628) 243-0550.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 11 deficiencies cited in the last three years
- Not rated family caregiver rating
- Not available CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
11 deficiencies cited in the last three years
The middle of the 14 hospices serving ZIP code 94903 had 4.5.
The last inspection on record was on Sep 1, 2026: a complaint inspection by the state.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
11 deficiencies in 1 month of the last 36. Last cited May 2024. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
May 22, 2024: reaccreditation inspection by the Accreditation Commission for Health Care11 deficiencies
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Timeframe for completion of assessment (42 CFR 418.54(b))
“Upon patient record review 1 of 4 records, (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3: The record indicated the patient was admitted on 1/17/24, the Spiritual Assessment was completed on 1/25/24. The Spiritual Assessment was not completed within 5 calendar days after the election of hospice.”
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Content of comprehensive assessment (42 CFR 418.54(c)(6))
The inspectors’ words, 155 words
“Upon patient record review, 3 of 4 (Patient #1,2,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The caregiver was instructed by the nurse to stop taking Amlodipine and Losartan. In addition, the caregiver stated he gave the patient Ibuprofen which was not on the medication profile. Corrected on site. Patient #2: The caregiver has not given the patient Docusate Sodium as listed on the medication profile and it was not available in the home. Corrected on site. Patient #3: Medications were on the medication profile, Lorazepam, Morphine and Haloperidol, but not available in the home. Corrected on cite.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 104 words
“Upon patient record review, 2 of 4 records, (Patient #1, #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Upon observation home visit, the caregiver stated he was giving the patient Ibuprofen. There was not an order for ibuprofen. Patient #2: The record indicated an order on 4/30/24, “May change Foley catheter every 1 and PRN for leaking and complication”. There was not evidence of a specific frequency or specifics for catheter change (size, amount to inflate bulb) in the order.”
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Coordination of services (42 CFR 418.56(e)(2))
“Upon client record review, 1 of 4 records (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated on 2/16/24 the order stated change Foley every month. There is no evidence in the record that the Foley was changed until 5/3/24.”
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Prevention (42 CFR 418.60(a))
“Upon home visit observation, 1 of 3 home visits, (Patient#2), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, the RN cleaned dirty equipment with patient wipes. The wipes did not contain the appropriate percentage of alcohol for cleaning equipment.”
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Professional management responsibility (42 CFR 418.100(e))
The inspectors’ words, 105 words
“Upon contract review, 1 of 2 contracts (Access Therapy) did not have evidence that the agreement to furnish any services under arrangement includes that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Delivered in accordance with the patient’s plan of care •Any additional requirements as out lined in the Social Security Act section 1861(w) •There are copies of professional liability insurance certificates on file for any contract personnel providing direct patient care. Corrected on site.”
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Content (42 CFR 418.104(a)(6))
“Upon patient client record review, 2 of 4 records, (Patient #1, #2) did not have evidence that each patient record contained Advance Directives. Patient #1, #2: The record indicated that the patient had an advanced directive. There was not evidence that an advanced directive was a part of the chart. Corrected on site.”
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Authentication (42 CFR 418.104(b))
The inspectors’ words, 94 words
“Upon patient client record review, 1 of 4 records, (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: The Bereavement Coordinator documentation indicated the patient’s date of death was 2/22/24. A Bereavement condolence call was placed on 2/21/24. The Agency staff indicated the patient’s date of death was 2/20/24.”
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Inpatient care provided under arrangements (42 CFR 418.108(c)(1))
“Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care) did not have evidence of a provision that the hospice supplies the inpatient provider with a copy of the patient’s plan of care and specifies the inpatient services to be furnished. Corrected on site.”
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Inpatient care provided under arrangements (42 CFR 418.108(c)(2))
“Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care ) did not have evidence of a provision that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. Corrected on site.”
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Inpatient care provided under arrangements (42 CFR 418.108(c)(3))
“Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care) did not have evidence of a provision that the hospice patient’s inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Corrected on site.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 1, 2026 | Complaint inspection by the state | No deficiencies cited |
| May 22, 2024 | Reaccreditation inspection by the Accreditation Commission for Health Care | 11 deficiencies cited |
Is it certified?
- Medicare-certified hospice since May 25, 2021.
- Ownership: for-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- CMS hasn’t published nursing time from Medicare claims for this hospice.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 100% at home.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
Who owns it?
- 8 owners or officers are people: Leopoldo L Reyes (owns 5% or more directly, 50%); Leopoldo L Reyes (corporate officer, 50%); Leopoldo L Reyes (corporate director, 50%); Leopoldo L Reyes (managing employee (on the payroll), 50%); Gloria M Escano (owns 5% or more directly, 50%); Gloria M Escano (corporate officer, 50%); Gloria M Escano (corporate director, 50%); Gloria M Escano (managing employee (on the payroll), 50%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS gives no Hospice Care Index for this hospice.
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
How does it compare nearby?
- Of the 14 hospices CMS’s data show serving patients in ZIP code 94903, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4.5; this one had 11.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Madrona Hospice Care Inc. This hospice | 11 |
| Sutter Care at Home | 0 |
| By the Bay Health | 6 |
| Sutter Care at Home | 5 |
| Suncrest Hospice | 4 |
| Continuum Care Hospice LLC | 7 |
| MD Choice Hospice, Inc. | 4 |
| Holistic Palliative Care, Inc. | 4 |
| Caring Heart Hospice Inc. | 9 |
| Anchor Health | 2 |
| Best Hospice Provider, Inc. | 11 |
| Sehaj Hospice Care, Inc. | 10 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.