Cycle 1
Health 2026-01-02 · Fire 2026-01-02
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Duarte, CA
Royal Oaks Manor-Bradbury Oaks
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1763 Royal Oaks Drive, Duarte, CA
(626) 359-9371
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Humangood
Operator or chain grouping
Approved since
1992-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
1.59
Licensed practical nurse staffing
Aide hours / resident day
2.69
Nurse aide staffing
Weekend hours
4.35
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.3
0.9 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
98.5%
About the same
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
1.6%
1.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
6.8%
3.5 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.1%
3.3 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.8% |
13.7%
6.9 pts better
|
19.6%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
14.2%
11.4 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.2% |
11.0%
22.2 pts worse
|
16.3%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.5% |
10.7%
10.8 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.0%
3 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
1.2%
5.4 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
10.9%
19.9 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.7%
0.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
94.0%
3.5 pts worse
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.2%
3.6 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
93.2%
0.7 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.2% |
23.2%
12 pts better
|
23.9%
12.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-15 · Fire 2024-11-15
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-02 · Fire 2023-11-02
16 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2026-01-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-22
D · Potential for more than minimal harm
2024-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-13
D · Potential for more than minimal harm
2023-11-02
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-12-02
D · Potential for more than minimal harm
2023-11-02
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-12-02
D · Potential for more than minimal harm
2023-11-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-02
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-21
E · Potential for more than minimal harm
2026-01-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-07
E · Potential for more than minimal harm
2026-01-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-19
E · Potential for more than minimal harm
2026-01-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-08
D · Potential for more than minimal harm
2026-01-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-22
D · Potential for more than minimal harm
2026-01-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-15
D · Potential for more than minimal harm
2026-01-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-16
D · Potential for more than minimal harm
2026-01-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-12-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-05
E · Potential for more than minimal harm
2024-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-15
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-10-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-24
G · Actual harm
2024-05-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-29
G · Actual harm
2024-04-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-10
D · Potential for more than minimal harm
2023-11-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-11-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-11-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-11-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-11-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-14
E · Potential for more than minimal harm
2023-11-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-14
E · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-11-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-11-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-11-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-14
Penalties and ownership
What sits behind the stars
$0
2024-04-15
Payment Denial
Payment Denial · denial start 2024-05-14 · 15 days
15 day denial
Ownership
Humangood
5% Or Greater Indirect Ownership Interest · Organization
Humangood Socal
5% Or Greater Direct Ownership Interest · Organization
Agoniollo, Jose Antonio
Operational/Managerial Control · Individual
Arevalo, Jocelyn
Operational/Managerial Control · Individual
Baker, Judith
Operational/Managerial Control · Individual
Baker, Judith
Corporate Director · Individual
Battison, William
Operational/Managerial Control · Individual
Battison, William
Corporate Director · Individual
Brown, Herman
Operational/Managerial Control · Individual
Brown, Herman
Corporate Director · Individual
Chien, Norman
Operational/Managerial Control · Individual
Christopherson, Joanne
Operational/Managerial Control · Individual
Christopherson, Joanne
Corporate Director · Individual
Cochrane, John
Operational/Managerial Control · Individual
Cochrane, John
Corporate Officer · Individual
Feller, Irene
Operational/Managerial Control · Individual
Feller, Irene
Corporate Director · Individual
Ghassemi, Bethany
Operational/Managerial Control · Individual
Ghassemi, Bethany
Corporate Officer · Individual
Griffith, Alan
Operational/Managerial Control · Individual
Griffith, Alan
Corporate Director · Individual
Holmes, Michelle
Operational/Managerial Control · Individual
Holmes, Michelle
Corporate Director · Individual
Hovsepian Bearce, Jeremiah
Operational/Managerial Control · Individual
Humangood Norcal
Operational/Managerial Control · Organization
Humangood Socal
Operational/Managerial Control · Organization
Kelley, Albert
Operational/Managerial Control · Individual
Kelley, Albert
Corporate Director · Individual
Mcdonald, Andrew
Operational/Managerial Control · Individual
Mcdonald, Andrew
Corporate Officer · Individual
Ogus, Daniel
Operational/Managerial Control · Individual
Ogus, Daniel
Corporate Officer · Individual
Roth, Sharon
Corporate Director · Individual
Smith, Andrew
Operational/Managerial Control · Individual
U.s. Bank
5% Or Greater Security Interest · Organization
Vangelisto, Gwen
Operational/Managerial Control · Individual
Nearby options
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Duarte, CA
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Monte Vista Healthcare Center
Duarte, CA
2-star overall rating with 2-star inspections with $10,488 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Monrovia Post Acute
Duarte, CA
3-star overall rating with 2-star inspections with 28 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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