Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive, Duarte, CA 91010
Royal Oaks Manor-Bradbury Oaks is a nursing home in Duarte, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (626) 359-9371
- Last standard health inspection
- January 2, 2026 (10 months ago)
- Certified beds
- 48
- Residents per day, on average
- 42.3
- Ownership type
- Non profit - Corporation
- Legal business name
- Humangood Socal
- Chain
- Humangood
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (42 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
8 citations
Health inspection on January 2, 2026
CMS lists this as a standard inspection.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor 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.
CMS lists it as corrected on January 21, 2026.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on January 7, 2026.
CMS has cited this home for F0677 2 times since 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 19, 2026.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 8, 2026.
CMS has cited this home for F0880 4 times since 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 22, 2026.
CMS has cited this home for F0550 2 times since 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on January 15, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 16, 2026.
CMS has cited this home for F0684 4 times since 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on January 15, 2026.
CMS has cited this home for F0756 2 times since 2023.
1 citation
Fire safety inspection on January 2, 2026
CMS lists this as a standard inspection.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on January 22, 2026.
CMS has cited this home for K0355 2 times since 2024.
2 citations
Health inspection on December 1, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 5, 2025.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on December 5, 2025.
CMS has cited this home for F0919 2 times since 2024.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
13 citations
Health inspection on November 15, 2024
CMS lists this as a standard inspection.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 15, 2024.
CMS has cited this home for F0656 2 times since 2023.
Citation F0700. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Try 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.
CMS lists it as corrected on December 15, 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 15, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 15, 2024.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on December 15, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on December 15, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on December 15, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 15, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 15, 2024.
CMS has cited this home for F0689 3 times since 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on December 15, 2024.
CMS has cited this home for F0760 2 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on December 15, 2024.
5 citations
Fire safety inspection on November 15, 2024
CMS lists this as a standard inspection.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 13, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 13, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 13, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on December 13, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 13, 2024.
1 citation
Health inspection on October 5, 2024
CMS lists this as a complaint inspection.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on October 24, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 4.7 to 4.2 hours per resident per day.
Payment stopped
May 14, 2024 (2 years ago)
CMS stopped payment for new admissions from May 14, 2024, for 15 days.
1 citation
Health inspection on May 10, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 29, 2024.
1 citation
Health inspection on April 15, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.
Citation F0744. Severity G: actual harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on May 10, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on November 28, 2023
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 11, 2023.
15 citations
Health inspection on November 2, 2023
CMS lists this as a standard inspection.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on November 6, 2023.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on November 10, 2023.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 10, 2023.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 22, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 16, 2023.
Citation F0760. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on November 14, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 14, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 2, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on November 20, 2023.
Citation F0573. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
CMS lists it as corrected on November 20, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 10, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 9, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on November 20, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 20, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on November 14, 2023.
3 citations
Fire safety inspection on November 2, 2023
CMS lists this as a standard inspection.
Citation K0331. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Construct fire resistant interior walls.
CMS lists it as corrected on December 2, 2023.
Citation K0361. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
CMS lists it as corrected on December 2, 2023.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 2, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- HUMANGOOD SOCAL5% or greater direct ownership interest · 100% · since 02/02/1988
- HUMANGOOD5% or greater indirect ownership interest · 100% · since 05/01/2016
- HUMANGOOD NORCALOperational/managerial control · not applicable · since 04/15/1992
- HUMANGOOD SOCALOperational/managerial control · not applicable · since 01/01/1967
- AGONIOLLO, JOSE ANTONIOOperational/managerial control · not applicable · since 03/21/2022
- AREVALO, JOCELYNOperational/managerial control · not applicable · since 09/03/2024
- BAKER, JUDITHOperational/managerial control · not applicable · since 05/01/2016
- BATTISON, WILLIAMOperational/managerial control · not applicable · since 05/01/2016
- BROWN, HERMANOperational/managerial control · not applicable · since 02/10/2013
- CHIEN, NORMANOperational/managerial control · not applicable · since 11/01/2008
- CHRISTOPHERSON, JOANNEOperational/managerial control · not applicable · since 03/20/2025
- COCHRANE, JOHNOperational/managerial control · not applicable · since 08/10/2009
- FELLER, IRENEOperational/managerial control · not applicable · since 01/26/2021
- GHASSEMI, BETHANYOperational/managerial control · not applicable · since 05/21/2019
- GRIFFITH, ALANOperational/managerial control · not applicable · since 06/30/2019
- HOLMES, MICHELLEOperational/managerial control · not applicable · since 05/01/2016
- HOVSEPIAN BEARCE, JEREMIAHOperational/managerial control · not applicable · since 11/24/2024
- KELLEY, ALBERTOperational/managerial control · not applicable · since 05/01/2016
- MCDONALD, ANDREWOperational/managerial control · not applicable · since 01/01/2020
- OGUS, DANIELOperational/managerial control · not applicable · since 10/17/1995
- SMITH, ANDREWOperational/managerial control · not applicable · since 09/15/2024
- VANGELISTO, GWENOperational/managerial control · not applicable · since 08/30/2021
Questions
When was Royal Oaks Manor-Bradbury Oaks last inspected?
CMS lists January 2, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Royal Oaks Manor-Bradbury Oaks have?
CMS lists 42 health citations since November 2, 2023. CMS also calls these deficiencies.
Has Royal Oaks Manor-Bradbury Oaks been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Royal Oaks Manor-Bradbury Oaks?
Its CMS overall star rating is 4 of 5.
Is Royal Oaks Manor-Bradbury Oaks a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.