Royal Oaks Manor-Bradbury Oaks
Duarte, Los Angeles County, California · CCN 555503 · Non-profit (Corporation) · part of Humangood (17 facilities, chain average 4.5 stars)
CMS rates Royal Oaks Manor-Bradbury Oaks 4 of 5 overall as of August 2026. 48 certified beds, 43 residents a day on average. 42 citations on record from the current inspection cycles, 2 involving actual harm; no fines on record and 1 payment denial.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 2 / 5 of 5 |
Staffing
| Total nurse staffing | 4.80728 hours per resident per day |
|---|---|
| Registered nurses | 0.60567 hours per resident per day |
| Weekend total | 4.43949 hours per resident per day |
| Nursing staff turnover | 30.8% (registered nurses 37.5%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-01-02 | 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 · tag F0578 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-21 |
| 2026-01-02 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-07 |
| 2026-01-02 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-19 |
| 2026-01-02 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-08 |
| 2026-01-02 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-22 |
| 2026-01-02 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-15 |
| 2026-01-02 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-16 |
| 2026-01-02 | 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 · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-15 |
| 2025-12-01 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-12-05 |
| 2025-12-01 complaint survey |
Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-12-05 |
| 2024-11-15 | 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 · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | 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 · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | 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 · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | 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 · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-11-15 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-15 |
| 2024-10-05 complaint survey |
Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-24 |
| 2024-05-10 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-05-29 |
| 2024-04-15 complaint survey |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-05-10 |
| 2023-11-28 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-11 |
| 2023-11-02 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-06 |
| 2023-11-02 | 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 Deficiencies · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-10 |
| 2023-11-02 | 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 · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-10 |
| 2023-11-02 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-22 |
| 2023-11-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-16 |
| 2023-11-02 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-14 |
| 2023-11-02 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-14 |
| 2023-11-02 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-02 |
| 2023-11-02 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-11-02 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · tag F0573 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-11-02 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-10 |
| 2023-11-02 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-09 |
| 2023-11-02 | 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 · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-11-02 | 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 · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-11-02 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-14 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-04-15 | Payment denial for 15 days from 2024-05-14 | — |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Humangood Socal Organization | 5% or greater direct ownership interest | 100% | 1988-02-02 |
| Humangood Organization | 5% or greater indirect ownership interest | 100% | 2016-05-01 |
| U.S. Bank Organization | 5% or greater security interest | — | 2025-04-08 |
| Baker Tilly Advisory Group Lp Organization | adp of the snf | — | 2025-03-21 |
| Baker Tilly US LLP Organization | adp of the snf | — | 2024-10-15 |
| Hansen Hunter LLC Organization | adp of the snf | — | 2017-03-27 |
| Humangood Organization | adp of the snf | — | 2025-04-10 |
| Humangood Norcal Organization | adp of the snf | — | 1992-04-15 |
| Humangood Socal Organization | adp of the snf | — | 1967-01-01 |
| U.S. Bank Organization | adp of the snf | — | 2025-04-08 |
| Washington Federal Organization | adp of the snf | — | 2020-11-06 |
| Humangood Norcal Organization | operational/managerial control | — | 1992-04-15 |
| Humangood Socal Organization | operational/managerial control | — | 1967-01-01 |
| Agoniollo, Jose Antonio Individual | adp of the snf | — | 2022-03-21 |
| Arevalo, Jocelyn Individual | adp of the snf | — | 2024-09-03 |
| Chien, Norman Individual | adp of the snf | — | 2008-11-01 |
| Hovsepian Bearce, Jeremiah Individual | adp of the snf | — | 2024-11-24 |
| Vangelisto, Gwen Individual | adp of the snf | — | 2021-08-30 |
| Baker, Judith Individual | corporate director | — | 2012-04-25 |
| Battison, William Individual | corporate director | — | 2011-02-03 |
| Brown, Herman Individual | corporate director | — | 2016-05-01 |
| Christopherson, Joanne Individual | corporate director | — | 2025-03-20 |
| Feller, Irene Individual | corporate director | — | 2021-01-26 |
| Griffith, Alan Individual | corporate director | — | 2019-06-30 |
| Holmes, Michelle Individual | corporate director | — | 2016-05-01 |
| Kelley, Albert Individual | corporate director | — | 2008-04-21 |
| Roth, Sharon Individual | corporate director | — | 2018-12-08 |
| Cochrane, John Individual | corporate officer | — | 2009-08-10 |
| Ghassemi, Bethany Individual | corporate officer | — | 2019-05-21 |
| Mcdonald, Andrew Individual | corporate officer | — | 2020-01-01 |
| Ogus, Daniel Individual | corporate officer | — | 2009-08-27 |
| Agoniollo, Jose Antonio Individual | operational/managerial control | — | 2022-03-21 |
| Arevalo, Jocelyn Individual | operational/managerial control | — | 2024-09-03 |
| Baker, Judith Individual | operational/managerial control | — | 2016-05-01 |
| Battison, William Individual | operational/managerial control | — | 2016-05-01 |
| Brown, Herman Individual | operational/managerial control | — | 2013-02-10 |
| Chien, Norman Individual | operational/managerial control | — | 2008-11-01 |
| Christopherson, Joanne Individual | operational/managerial control | — | 2025-03-20 |
| Cochrane, John Individual | operational/managerial control | — | 2009-08-10 |
| Feller, Irene Individual | operational/managerial control | — | 2021-01-26 |
| Ghassemi, Bethany Individual | operational/managerial control | — | 2019-05-21 |
| Griffith, Alan Individual | operational/managerial control | — | 2019-06-30 |
| Holmes, Michelle Individual | operational/managerial control | — | 2016-05-01 |
| Hovsepian Bearce, Jeremiah Individual | operational/managerial control | — | 2024-11-24 |
| Kelley, Albert Individual | operational/managerial control | — | 2016-05-01 |
| Mcdonald, Andrew Individual | operational/managerial control | — | 2020-01-01 |
| Ogus, Daniel Individual | operational/managerial control | — | 1995-10-17 |
| Smith, Andrew Individual | operational/managerial control | — | 2024-09-15 |
| Vangelisto, Gwen Individual | operational/managerial control | — | 2021-08-30 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Royal Oaks Manor-Bradbury Oaks.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.