Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive · Duarte, CA · 91010 · 6263599371
48 certified beds Non profit - Corporation Chain: Humangood Part of a CCRC
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The composite number cleared 73 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.74 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.54 | 0.55–0.75 |
| Weekend hours / resident-day | 4.31 | ≈ weekday level |
| Nursing turnover / year | 28% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (42 in the current record)
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Potential for harm · D January 2, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 22, 2026 · Resident Rights
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Potential for harm · E January 2, 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.
Corrected January 21, 2026 · Resident Rights
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Potential for harm · D January 2, 2026
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected January 15, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 2, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 7, 2026 · Quality of Life and Care
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Potential for harm · D January 2, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 16, 2026 · Quality of Life and Care
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Potential for harm · E January 2, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 19, 2026 · Pharmacy Service
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Potential for harm · D January 2, 2026
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E January 2, 2026
Provide and implement an infection prevention and control program.
Corrected January 8, 2026 · Infection Control
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Potential for harm · E December 1, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 5, 2025 · Quality of Life and Care
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Potential for harm · E December 1, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected December 5, 2025 · Environmental
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Potential for harm · E November 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 15, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 15, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 15, 2024 · Quality of Life and Care
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Potential for harm · D November 15, 2024
Provide activities to meet all resident's needs.
Corrected December 15, 2024 · Quality of Life and Care
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Potential for harm · D November 15, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 15, 2024 · Quality of Life and Care
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Potential for harm · D November 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 15, 2024 · Quality of Life and Care
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Potential for harm · E November 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.
Corrected December 15, 2024 · Quality of Life and Care
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Potential for harm · D November 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.
Corrected December 15, 2024 · Pharmacy Service
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Potential for harm · D November 15, 2024
Ensure that residents are free from significant medication errors.
Corrected December 15, 2024 · Pharmacy Service
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Potential for harm · D November 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.
Corrected December 15, 2024 · Pharmacy Service
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Potential for harm · E November 15, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 15, 2024 · Resident Assessment and Care Planning
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Potential for harm · E November 15, 2024
Provide and implement an infection prevention and control program.
Corrected December 15, 2024 · Infection Control
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Potential for harm · D November 15, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected December 15, 2024 · Infection Control
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Potential for harm · E November 15, 2024
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected December 15, 2024 · Environmental
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Potential for harm · D October 5, 2024 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 24, 2024 · Quality of Life and Care
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Actual harm · G May 10, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 29, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 15, 2024 | Payment Denial | 15 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555503 · certified since April 15, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.