Nursing home report card · Duarte, CA
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive, Duarte, CA 91010
Call this home: (626) 359-9371
View this home on Medicare.gov ↗
Quick summary
Review the ratings and inspection history below
Use the star ratings as a quick grade, then read what inspectors actually wrote. Numbers alone do not tell the whole story for any one resident.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Jan 2, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Above average
Based on problems found during health inspections.
About average for U.S. nursing homes
Based on staffing levels and related measures.
Among the highest Medicare ratings
Based on reported health and care results.
Above average
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 555503
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Caused actual harm · isolated case
May 10, 2024 · Inspection rule 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Caused actual harm · isolated case
Apr 15, 2024 · Inspection rule 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Could have caused harm · isolated case
Jan 2, 2026 · Inspection rule 0644
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 36 minutes per resident per day
about 4 hr 48 min per resident per day
about 37 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 4 stars
- Health inspection rating: 3 stars
- Staffing rating: 5 stars
- Registered nurse time per resident: 0.61 hours/day
- Total nurse time per resident: 4.81 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; California averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Caused actual harm2 citations
- Could have caused harm40 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 42
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as Non profit - Corporation.
- We do not have individual owner names for this home.
Other homes in this group: All Humangood nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
January 2, 20268 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0644 · code D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0578 · code E
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.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0756 · code D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
December 1, 20252 findings
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0919 · code E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
November 15, 202413 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0679 · code D
Provide activities to meet all resident's needs.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
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…
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code D
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.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0883 · code D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0919 · code E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0700 · code E
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 r…
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0842 · code E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
October 5, 20241 finding
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0697 · code D
Provide safe, appropriate pain management for a resident who requires such services.
May 10, 20241 finding
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
April 15, 20241 finding
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0744 · code G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
November 28, 20231 finding
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
November 2, 202315 findings
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0655 · code E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code E
Ensure that residents are free from significant medication errors.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0554 · code D
Allow residents to self-administer drugs if determined clinically appropriate.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0756 · code D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
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…
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code D
Ensure medication error rates are not 5 percent or greater.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0573 · code D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Payment Denial · Apr 15, 2024Unavailable
Other homes in this chain
Humangood · other locations in California
- The Terraces at Los Altos Health Facility · Los Altos4 of 5 · 38 problems
- Rosewood Health Facility · Bakersfield4 of 5 · 47 problems
- Regents Point - Windcrest · Irvine4 of 5 · 38 problems
- Plymouth Village · Redlands4 of 5 · 23 problems
- The Terraces at San Joaquin Gardens Village · Fresno5 of 5 · 31 problems
- Piedmont Gardens Health Facility · Oakland5 of 5 · 11 problems
- Redwood Terrace Health Center · Escondido5 of 5 · 17 problems
- The Terraces of Los Gatos · Los Gatos5 of 5 · 30 problems
Related topics
Questions about Royal Oaks Manor-Bradbury Oaks
What is Royal Oaks Manor-Bradbury Oaks's Medicare star rating?
Has Royal Oaks Manor-Bradbury Oaks been fined?
Does Royal Oaks Manor-Bradbury Oaks have a Medicare abuse warning?
How does Royal Oaks Manor-Bradbury Oaks compare with other nursing homes in California?
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