Royal Oaks Manor-Bradbury Oaks

Name: Royal Oaks Manor-Bradbury Oaks
Address: 1763 ROYAL OAKS DRIVE, Duarte, CA, 91010, US
Telephone: 6263599371

1763 Royal Oaks Drive, Duarte, CA 91010 · Los Angeles County · 48 certified beds · avg 43 residents/day · certified since Apr 15, 1992

Part of chain: HUMANGOOD (17 facilities, chain avg rating 4.5★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.14

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · May 10, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 29, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 15, 2024 · F-0744 · triggered by a complaint

The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.

Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 10, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (42)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 2, 2026	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jan 2, 2026	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 2, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 2, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 2, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jan 2, 2026	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Jan 2, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 2, 2026	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Dec 1, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 1, 2025	E · Potential for harm, repeated	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Nov 15, 2024	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Nov 15, 2024	E · Potential for harm, repeated	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Nov 15, 2024	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Nov 15, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 15, 2024	E · Potential for harm, repeated	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 15, 2024	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Oct 5, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
May 10, 2024	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 15, 2024	▲ G · Actual harm, one-off	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
Nov 28, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 2, 2023	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Nov 2, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not let a resident or their legal representative see or buy copies of the resident's own records.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Nov 2, 2023	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Nov 2, 2023	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (13 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2023	16	0	E
2024	16	2	G ▲
2025	2	0	E
2026	8	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

0 fines totaling $0, plus 1 Medicare payment denial period.

Date	Type	Amount / length
Apr 15, 2024	Payment Denial	15 days from May 14, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.14	4.31	3.95	top 12% in California; top 11% in the U.S.
Registered Nurse hours	0.65	0.61	0.69	top 28% in California; top 42% in the U.S.
Weekend total nurse staffing	4.75	3.90	3.50	top 9% in California; top 9% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.62	0.51	0.48	top 20% in California; top 22% in the U.S.
Total nursing staff turnover (%)	30.8	36.7	45.8	top 32% in California; top 16% in the U.S.
RN turnover (%)	37.5	38.1	42.9	top 50% in California; top 42% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.81, RN 0.61, weekend 4.44. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Humangood	Organization	5% or Greater Indirect Ownership Interest	100%	05/01/2016
Humangood Socal	Organization	5% or Greater Direct Ownership Interest	100%	02/02/1988
Agoniollo, Jose Antonio	Individual	Operational/Managerial Control	NOT APPLICABLE	03/21/2022
Agoniollo, Jose Antonio	Individual	ADP of the SNF	NOT APPLICABLE	03/21/2022
Arevalo, Jocelyn	Individual	Operational/Managerial Control	NOT APPLICABLE	09/03/2024
Arevalo, Jocelyn	Individual	ADP of the SNF	NOT APPLICABLE	09/03/2024
Baker Tilly Advisory Group LP	Organization	ADP of the SNF	NOT APPLICABLE	03/21/2025
Baker Tilly Us LLP	Organization	ADP of the SNF	NOT APPLICABLE	10/15/2024
Baker, Judith	Individual	Corporate Director	NOT APPLICABLE	04/25/2012
Baker, Judith	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Battison, William	Individual	Corporate Director	NOT APPLICABLE	02/03/2011
Battison, William	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Brown, Herman	Individual	Corporate Director	NOT APPLICABLE	05/01/2016
Brown, Herman	Individual	Operational/Managerial Control	NOT APPLICABLE	02/10/2013
Chien, Norman	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2008
Chien, Norman	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2008
Christopherson, Joanne	Individual	Corporate Director	NOT APPLICABLE	03/20/2025
Christopherson, Joanne	Individual	Operational/Managerial Control	NOT APPLICABLE	03/20/2025
Cochrane, John	Individual	Corporate Officer	NOT APPLICABLE	08/10/2009
Cochrane, John	Individual	Operational/Managerial Control	NOT APPLICABLE	08/10/2009

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Royal Terrace Healthcare	0.4 mi	Duarte, CA	★★★☆☆	2/5
Monte Vista Healthcare Center	0.6 mi	Duarte, CA	★★☆☆☆	2/5
Monrovia Post Acute	0.6 mi	Duarte, CA	★★★☆☆	2/5
Monrovia Gardens Healthcare Center	2.4 mi	Monrovia, CA	★☆☆☆☆	1/5
Sierra View Care Center	3.4 mi	Baldwin Park, CA	★★★★☆	3/5
Santa Fe Lodge	3.5 mi	El Monte, CA	★★☆☆☆	2/5
Mayflower Care Center	3.5 mi	El Monte, CA	★★★☆☆	3/5
Coast Care Convalescent Center	3.6 mi	Baldwin Park, CA	★★★★☆	4/5
The Gardens of el Monte	4.2 mi	El Monte, CA	★★☆☆☆	2/5
Fidelity Health Care	4.6 mi	El Monte, CA	★★★☆☆	2/5	abuse

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 555503.

The Care File

Visit checklist — Royal Oaks Manor-Bradbury Oaks

1763 Royal Oaks Drive, Duarte, CA 91010 · 6263599371

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Most serious findings on record:

▲ May 10, 2024 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Apr 15, 2024 (F-0744, Actual harm, one-off): The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555503 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)