Nursing homeActive
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive, Duarte, CA 91010626359937148 certified beds · 43 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
8
since 2023
Deficiencies
42
● 0● 40● 2
Penalties · 3 yrs
—
1 action
Last survey
2026-01-02
Standard
CMS overall
4 / 5
stars as published by CMS
CMS overall 4/5
Health 3
Staffing 5
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-01-02 | Standard | 080 | CMS-2567 (Care Compare) | — |
| 2025-12-01 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-11-15 | Standard | 0130 | CMS-2567 (Care Compare) | — |
| 2024-10-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-05-10 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-04-15 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2023-11-28 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-11-02 | Standard | 0150 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-22Record 555503-20260102-F550
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 555503-20260102-F578
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-15Record 555503-20260102-F644
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-07Record 555503-20260102-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-16Record 555503-20260102-F684
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-19Record 555503-20260102-F755
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-15Record 555503-20260102-F756
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-08Record 555503-20260102-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-05Record 555503-20251201-F684
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-05Record 555503-20251201-F919
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F677
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F689
F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F700
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F758
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F761
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F883
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-15Record 555503-20241115-F919
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555503-20241005-F697
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-05-29Record 555503-20240510-F689
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-05-10Record 555503-20240415-F744
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-11Record 555503-20231128-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 555503-20231102-F550
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 555503-20231102-F554
F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 555503-20231102-F573
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 555503-20231102-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 555503-20231102-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 555503-20231102-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-09Record 555503-20231102-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-22Record 555503-20231102-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-16Record 555503-20231102-F689
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 555503-20231102-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 555503-20231102-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 555503-20231102-F759
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 555503-20231102-F760
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 555503-20231102-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-02Record 555503-20231102-F880
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-04-15 | Denial of payment for new admissions Payment denial for 15 days, from 2024-05-14 | — | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.61
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day4.81
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours4.44
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover31%
Facility
California
National
California 37% · National 46%
Registered nurse turnover38%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 9.6% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 19.1% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 3.4% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 18.6% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 8.3% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 3.4% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Humangood Socal Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Humangood Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | — | — |
| Agoniollo, Jose Antonio Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Arevalo, Jocelyn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Baker, Judith Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Battison, William Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Brown, Herman Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Chien, Norman Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Christopherson, Joanne Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Cochrane, John Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Feller, Irene Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ghassemi, Bethany Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Griffith, Alan Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Holmes, Michelle Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hovsepian Bearce, Jeremiah Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Humangood Norcal Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Humangood Socal Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Kelley, Albert Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mcdonald, Andrew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ogus, Daniel Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Smith, Andrew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Vangelisto, Gwen Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Agoniollo, Jose Antonio Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Arevalo, Jocelyn Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Baker Tilly Advisory Group LP Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Baker Tilly Us LLP Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Baker, Judith Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Battison, William Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Brown, Herman Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Chien, Norman Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Christopherson, Joanne Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Cochrane, John Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Feller, Irene Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Ghassemi, Bethany Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Griffith, Alan Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Hansen Hunter LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Holmes, Michelle Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Hovsepian Bearce, Jeremiah Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Humangood Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Humangood Norcal Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Humangood Socal Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Kelley, Albert Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Mcdonald, Andrew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Ogus, Daniel Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Roth, Sharon Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| U.S. Bank Organization | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE | — | — |
| U.S. Bank Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Vangelisto, Gwen Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Washington Federal Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Humangood — 17 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for Los Angeles.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Royal Terrace Healthcare Duarte | 0.4 mi | 2026-06-26 | 2380 |
| Monte Vista Healthcare Center Duarte | 0.6 mi | 2026-06-03 | 0470 |
| Monrovia Post Acute Duarte | 0.6 mi | 2026-06-10 | 0552 |
| Monrovia Gardens Healthcare Center Monrovia | 2.4 mi | 2026-06-23 | 0991 |
| Sierra View Care Center Baldwin Park | 3.4 mi | 2026-04-24 | 1440 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |