01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-02 | 10 | 2026-01-02 | 1 |
| Cycle 2 | 2024-11-15 | 14 | 2024-11-15 | 5 |
| Cycle 3 | 2023-11-02 | 18 | 2023-11-02 | 3 |
CMS CCN 5555032026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive · Duarte, CA 91010 · Los Angeles County
Certified beds48CMS provider file
Recent citation rows51current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
51 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-02 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-01-222026-01-02 · HEALTHF0578Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-212026-01-02 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2026-01-152026-01-02 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-01-072026-01-02 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-01-162026-01-02 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-02-192026-01-02 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2026-01-152026-01-02 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-01-082026-01-02 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-01-222025-12-01 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2025-12-01 · HEALTHF0919Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2024-11-15 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0700Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-12-152024-11-15 · HEALTHF0919Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2024-12-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-15 | Payment Denial | $0 | 15 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HUMANGOOD SOCALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 02/02/1988
- HUMANGOODOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 05/01/2016
- U.S. BANKOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 04/08/2025
- BAKER, JUDITHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/25/2012
- BATTISON, WILLIAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/03/2011
- BROWN, HERMANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/2016
- CHRISTOPHERSON, JOANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/20/2025
- FELLER, IRENEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/26/2021
- GRIFFITH, ALANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/30/2019
- HOLMES, MICHELLEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/2016
- KELLEY, ALBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/21/2008
- ROTH, SHARONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/08/2018
- COCHRANE, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/10/2009
- GHASSEMI, BETHANYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/21/2019
- MCDONALD, ANDREWIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2020
- OGUS, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/27/2009
- HUMANGOOD NORCALOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/15/1992
- HUMANGOOD SOCALOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1967
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.81per resident day
RN hours0.61per resident day
Weekend nurse hours4.44per resident day
Staff turnover30.8%CMS reported field