Gardenia Garden, INC
Duarte · 0.0 mi · 6 beds
CitationsNoneSubstantiated0
Royal Oaks Manor-bradbury Oaks
1763 ROYAL OAKS DRIVE, Duarte, CA, 91010
Nursing home48 licensed beds0 citations on record
6 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 10 deficiencies against Royal Oaks Manor-bradbury Oaks in Duarte, California at its most recent standard inspection on 2026-01-02, 2 of them arising from complaints. 2 findings have been recorded at the actual-harm level. Medicare rates it 4 out of 5 overall.
4 / 5Medicare overall rating
48certified beds
10deficiencies at the last inspection
0immediate-jeopardy findings on record
2actual-harm findings on record
0federal fines
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.0
Actual harmA resident was harmed, but not placed in immediate danger.2
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.40
Potential for minimal harmThe least serious band.0
Most recentEEEEDDDDEEEEEEEDDDDD
The last 20 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
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.
Resident Rights Deficiencies · F0578 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · F0677 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · F0755 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · F0550 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · F0644 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
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 Deficiencies · F0756 · 2026-01-02 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2025-12-01 · from a complaint · No actual harm, potential for more than minimal harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · F0919 · 2025-12-01 · from a complaint · No actual harm, potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · F0656 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
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.
Quality of Life and Care Deficiencies · F0700 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · F0842 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · F0919 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · F0677 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · F0679 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0758 · 2024-11-15 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below4 of 5
Health inspectionBased on the last three inspection cycles3 of 5
StaffingNurse hours per resident, adjusted for how sick residents are5 of 5
Quality measuresResident outcomes reported by the home4 of 5
Nurse hours per resident per dayReported by the home to CMS4.80728
Nursing staff turnoverShare of nursing staff who left in a year30.8%
Penalties
What Medicare has fined this home
FinesCivil money penalties imposed by CMS0
Total fined$0
Payment denials and other penaltiesMedicare refusing to pay for new admissions is the usual one1
Ownership
Who owns Royal Oaks Manor-bradbury Oaks
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| HUMANGOOD SOCAL | Organization | 100% | since 02/02/1988 |
| HUMANGOOD | Organization | 100% | since 05/01/2016 |
| U.S. BANK | Organization | NOT APPLICABLE | since 04/08/2025 |
| BAKER, JUDITH | Individual | NOT APPLICABLE | since 04/25/2012 |
| BATTISON, WILLIAM | Individual | NOT APPLICABLE | since 02/03/2011 |
| BROWN, HERMAN | Individual | NOT APPLICABLE | since 05/01/2016 |
| CHRISTOPHERSON, JOANNE | Individual | NOT APPLICABLE | since 03/20/2025 |
| FELLER, IRENE | Individual | NOT APPLICABLE | since 01/26/2021 |
| GRIFFITH, ALAN | Individual | NOT APPLICABLE | since 06/30/2019 |
| HOLMES, MICHELLE | Individual | NOT APPLICABLE | since 05/01/2016 |
| KELLEY, ALBERT | Individual | NOT APPLICABLE | since 04/21/2008 |
| ROTH, SHARON | Individual | NOT APPLICABLE | since 12/08/2018 |
Part of the HUMANGOOD group.
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
Royal Oaks
Duarte · 0.1 mi · 250 beds
CitationsNoneSubstantiated0
California Homecare Services
Duarte · 0.3 mi
CitationsNoneSubstantiated0
Private Client Care Services
Duarte · 0.3 mi
CitationsNoneSubstantiated0
Synergy Homecare Duarte
Duarte · 0.3 mi
CitationsNoneSubstantiated0
Royal Terrace Healthcare
Duarte · 0.5 mi · 58 beds
Citations0Substantiated0
Contact
Ask Royal Oaks Manor-bradbury Oaks a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 555503.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction