Hearth Record

Royal Oaks Manor-Bradbury Oaks

A nursing home in Duarte, California 91010

1763 Royal Oaks Drive, Duarte, California 91010. (626) 359-9371.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 28, 2026.

The last 24 months 26 citations in 6 months of the last 36. Last cited Jan 2026. Most serious: actual harm (G). Every month

Each figure’s source sits beside it, in its section below.

What these words mean7
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
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.
Scope and severity (A to L)
CMS grades each nursing home deficiency with a letter. A to C: no actual harm, with potential for minimal harm. D to F: no actual harm, but potential for more. G to I: actual harm. J to L: immediate jeopardy. Within each band, the letter rises as more residents were affected or could be: one or a few, a pattern, or widespread. Source: CMS, nursing home scope and severity grid (State Operations Manual, chapter 7).
Nurse staffing hours
The hours registered nurses, licensed practical nurses and nurse aides worked, per resident per day, from the payroll records each home sends CMS. Source: CMS, Payroll-Based Journal.
Fines and payment denials
A fine (civil money penalty) is money CMS makes a nursing home pay when it falls short of federal rules. A payment denial means Medicare and Medicaid stop paying for new admissions until the home meets the rules again. Source: CMS; 42 CFR 488.430 and 488.417.
Capacity
The most people the licence or certification lets the place care for at once: residents, children, beds or apartments, as the state counts them. It isn’t how many are there now. Source: Each state’s licensing agency.

What did inspectors find?

10 health citations at the latest inspection cycle

The California average is 15.7.

Last standard inspection Jan 2, 2026.

Most serious in three years: actual harm (G), at a complaint inspection on May 10, 2024

Source:

CMS, Provider Information, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

When those citations happened

26 citations in 6 months of the last 36. Last cited Jan 2026. Most serious: actual harm (G). The last 3 years, to Nov 5, 2026.

26 citations by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

All 27 citations in the last three years

Grouped by inspection, newest first. Each carries , from A, the least serious, to L, the most. 6 came from complaint inspections.

Source:

CMS, Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Jan 2, 2026: standard inspection8 citations
  • Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 22, 2026.

  • 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.

    Rule F0578. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 21, 2026.

  • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    Rule F0644. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 15, 2026.

  • Provide care and assistance to perform activities of daily living for any resident who is unable.

    Rule F0677. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 7, 2026.

  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 16, 2026.

  • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Rule F0755. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 19, 2026.

  • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 15, 2026.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 8, 2026.

Dec 1, 2025: complaint inspection2 citations
  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 5, 2025.

  • Make sure that a working call system is available in each resident’s bathroom and bathing area.

    Rule F0919. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 5, 2025.

Nov 15, 2024: standard inspection13 citations
  • Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

    Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Provide care and assistance to perform activities of daily living for any resident who is unable.

    Rule F0677. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Provide activities to meet all resident’s needs.

    Rule F0679. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • 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.

    Rule F0700. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • 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.

    Rule F0758. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Ensure that residents are free from significant medication errors.

    Rule F0760. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • 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.

    Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Rule F0842. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Develop and implement policies and procedures for flu and pneumonia vaccinations.

    Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

  • Make sure that a working call system is available in each resident’s bathroom and bathing area.

    Rule F0919. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 15, 2024.

Oct 5, 2024: complaint inspection1 citation
  • Provide safe, appropriate pain management for a resident who requires such services.

    Rule F0697. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 24, 2024.

May 10, 2024: complaint inspection1 citation
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: May 29, 2024.

Apr 15, 2024: complaint inspection1 citation
  • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    Rule F0744. G: actual harm. From a complaint. Correction date, as CMS recorded it: May 10, 2024.

Nov 28, 2023: complaint inspection1 citation
  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 11, 2023.

Is it certified, and in good standing?

  • Certified for Medicare and Medicaid since Apr 15, 1992.
  • Not on CMS’s special focus list.
  • No abuse icon from CMS.
  • No change of ownership in the last 12 months.
  • CMS lists its ownership as non profit, corporation.
  • 48 certified beds.
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Has it been fined or penalized?

  • No fines in the last three years.
  • 1 Medicare payment denial in the last three years.
  • 6 citations in the last three years came from complaint inspections.
Source:

CMS, Penalties and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

On record, newest first
DateWhatDetail
Apr 15, 2024Medicare payment denial

Who does the caring?

4.81 nurse hours per resident per day

The California average is 4.54.

CMS publishes staffing about four months after the fact.

Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

Staffing measures
MeasureThis homeCalifornia average
Nurse hours per resident per day4.814.54
Of which registered nurses0.580.68
At weekends4.424.10
Nursing staff turnover22%36.6%
Registered nurse turnover33.3%37.8%
Administrators who left0Not given

Who owns it?

  • Humangood Socal owns 100% directly since Feb 2, 1988.
  • Humangood Norcal and Humangood Socal run it.
  • 36 owners or officers are people: Joanne Christopherson (corporate director); Joanne Christopherson (runs it (operational or managerial control)); William J Battison (corporate director); William J Battison (runs it (operational or managerial control)); Alan Griffith (corporate director); Alan Griffith (runs it (operational or managerial control)); Albert W Kelley (corporate director); Albert W Kelley (runs it (operational or managerial control)); Jeremiah Herand Hovsepian Bearce (runs it (operational or managerial control)); Jeremiah Herand Hovsepian Bearce (additional disclosable party (controls, leases property to, or provides services to the home)); John H. Cochrane (corporate officer); John H. Cochrane (runs it (operational or managerial control)); Sharon Roth (corporate director); Jose Antonio T Agoniollo (runs it (operational or managerial control)); Jose Antonio T Agoniollo (additional disclosable party (controls, leases property to, or provides services to the home)); Michelle M Holmes (corporate director); Michelle M Holmes (runs it (operational or managerial control)); Judith D Baker (corporate director); Judith D Baker (runs it (operational or managerial control)); Andrew Smith (runs it (operational or managerial control)); Herman Declan Brown (corporate director); Herman Declan Brown (runs it (operational or managerial control)); Jocelyn N Arevalo (runs it (operational or managerial control)); Jocelyn N Arevalo (additional disclosable party (controls, leases property to, or provides services to the home)); Bethany J Ghassemi (corporate officer); Bethany J Ghassemi (runs it (operational or managerial control)); Gwen Vangelisto (runs it (operational or managerial control)); Gwen Vangelisto (additional disclosable party (controls, leases property to, or provides services to the home)); Daniel Ogus (corporate officer); Daniel Ogus (runs it (operational or managerial control)); Andrew Mcdonald (corporate officer); Andrew Mcdonald (runs it (operational or managerial control)); Irene Feller (corporate director); Irene Feller (runs it (operational or managerial control)); Norman T Chien (runs it (operational or managerial control)); Norman T Chien (additional disclosable party (controls, leases property to, or provides services to the home)).
  • Part of Humangood (17 homes in CMS’s data).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, All Owners. Checked Nov 5, 2026. Updated monthly.

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Organisations CMS lists
OrganisationRoleShareSince
Humangood SocalOwns 5% or more directly100%Feb 2, 1988
HumangoodOwns 5% or more through other companies100%May 1, 2016
U.s. BankHolds 5% or more security interest31%Apr 8, 2025
Hansen Hunter LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Mar 27, 2017
Baker Tilly Us LLPAdditional disclosable party (controls, leases property to, or provides services to the home)Oct 15, 2024
Washington Federal BankAdditional disclosable party (controls, leases property to, or provides services to the home)Nov 6, 2020
Humangood NorcalRuns it (operational or managerial control)Apr 15, 1992
Humangood NorcalAdditional disclosable party (controls, leases property to, or provides services to the home)Apr 15, 1992
Baker Tilly Advisory Group LPAdditional disclosable party (controls, leases property to, or provides services to the home)Mar 21, 2025
Humangood SocalRuns it (operational or managerial control)Jan 1, 1967
Humangood SocalAdditional disclosable party (controls, leases property to, or provides services to the home)Jan 1, 1967
U.s. BankAdditional disclosable party (controls, leases property to, or provides services to the home)Apr 8, 2025
HumangoodAdditional disclosable party (controls, leases property to, or provides services to the home)Apr 10, 2025

How do residents fare?

  • CMS rates its quality measures 4 of 5 (California average 4.2).
Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

CMS’s star ratings, from 1 to 5
MeasureRating
Overall rating4 of 5
Health inspections3 of 5
Staffing5 of 5
Quality measures4 of 5

How does it compare nearby?

  • Among the 12 nearest homes, within 4.7 miles, this one had the 10th most health citations at the latest inspection cycle (10; the middle value was 14.5).
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

The 12 nearest, by straight-line distance
PlaceMiles awayCitations, latest cycle
Royal Oaks Manor-Bradbury Oaks This nursing home10
Royal Terrace Healthcare0.412
Monte Vista Healthcare Center0.621
Monrovia Post Acute0.620
Monrovia Gardens Healthcare Center2.426
Sierra View Care Center3.411
Santa Fe Lodge3.516
Mayflower Care Center3.510
Coast Care Convalescent Center3.610
The Gardens of El Monte4.226
Fidelity Health Care4.613
Temple City Healthcare4.729

What the record doesn’t say

  • Complaints that didn’t lead to a citation aren’t published.
  • Inspections reach CMS’s data about six weeks after they happen, and staffing about four months after.
  • CMS publishes the inspectors’ full written findings in a separate monthly file, which isn’t loaded yet.
  • Fines and Medicare payment denials are the only enforcement CMS publishes; state licence actions aren’t included.

Sources

  • Centers for Medicare & Medicaid Services, Provider Information (4pq5-n9py).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Health Deficiencies (r5ix-sfxw).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Penalties (g6vv-u9sr).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, All Owners (afe44b85-cc6d-40d7-b5df-00ae8910d1d2).

    Checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, State and US Averages (xcdc-v8bm).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. 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.

Source:

This copy of the record was made on Nov 5, 2026.

From the home

The public record above comes first. Anything the home adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the home 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 home”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

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