Annual Utilization Report of Long Term Care Facilities
Facility Name:PROVIDENCE ST. ELIZABETH CARE CENTER
OSHPD ID:206190752Report Status:Submitted
License Category:Skilled Nursing FacilityReport Year:2017
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Facility Description
Section 3 - Census and Utilization
Section 4 - Patient Demographics
Section 5 - Major Capital Expenditures
Errors and Warnings
Section 1 - General Information
1.Facility Name:PROVIDENCE ST. ELIZABETH CARE CENTER
2.OSHPD ID Number:206190752
3.Street Address:10425 MAGNOLIA BOULEVARD
4.City:NORTH HOLLYWOOD
5.Zip:91601
6.Facility Phone No.:(818) 980 - 3872 ext.
7.Administrator Name:Neil Silverstein
8.Administrator E-mail Addr:neil.silverstein@providence.org
9.Was this facility in operation at any time during the year?Yes
10.Operation Open From:1/1/2017
11.Operation Open To:12/31/2017
12.Name of Parent Corporation:Providence Health and Services
13.Corporate Business Address:501 S Buena Vista Street
14.City:Burbank
15.State:CA
16.Zip:91505 -
17.Person Completing Report:NEIL SILVERSTEIN
18.Report Preparer's Phone No.:818-980-3872
19.Fax No.:818-763-5947
20.E-mail Address:neil.silverstein@providence.org
30.Submitted by:206190752
31.Submitted Date and Time:1/9/2018 1:10:15 PM
Section 2 - Facility Description
LICENSE CATEGORY (Completed by OSHPD.)
Line
No.		(1)
1.License CategorySkilled Nursing Facility

LICENSE TYPE OF CONTROL
Line
No.		(1)
5.From the list below, select the ONE category that best describes the licensee type of control of your long-term care facility, i.e. the type of organization that owns the license. (There will be a drop down box in ALIRTS - see list of choices below.)Non-profit Corporation


Facility Certifications
From the certification categories below, check those categories for which your facility was certified or contracted during the year (Check all that apply.)
Line
No.		(1)
21.Medicare Skilled NursingYes
22.Medi-Cal Skilled NursingYes
23.Medi-Cal Skilled Nursing/Mentally Disordered (Special Treatment Program)No
24.Medi-Cal Intermediate Care (General)No
25.Medi-Cal Intermediate Care / Developmentally DisabledNo
26.Medi-Cal Subacute or Subacute - PediatricNo
Section 3 - Census and Utilization

Census and Patient Days
For each licensed bed category (columns 1 through 5), enter prior year ending census (line 1), admissions (line 2), discharges (line 3), current year ending census, and patient days (line5).
Line
No.
(1)



Skilled Nursing
(2)

Skilled Nursing Mentally Disordered
(3)



Intermediate Care		(4)
Intermediate Care Develop-
mentally Disabled
(5)


Congregate Living Health Facility
(6)




Hospice
(7)




Total
1.Dec 31, 2016 Census410000041
2.+ Admissions11800000118
3.- Discharges12200000122
4.Dec. 31, 2017 Census
(Total)		370000037
5.Patient Days for 201714,3650000014,365
7.Licensed Beds520000052
8.Licensed Bed Days18,9800000018,980

Patients Admitted From and Discharged To
LTC Patients admitted from and discharged to each place shown.
Line
No.		(1)
Admitted From		(2)
Discharged To
11.Home650
12.Hospital10734
13.State Hospital00
14.Other LTC44
15.Residential Board & Care*110
16.Other00
17.AWOL / AMA1
18.Death23
20.Total118122
*Include RCFE, ARF, Other Assisted Living Facilities, or a secured facility such as an Alzheimer's unit, jail or prison.

Patients By Payment Source On December 31
Number of patients in the facility on December 31, whose principal source of payment was from the sources shown.
Line
No.		(1)
Patients
21.Medicare5
22.Medi-Cal17
23.Managed Care*4
24.Private Insurance0
25.Self-Pay11
29.All Other0
30.Total37
* Include patients enrolled in Medicare and Medi-Cal managed care health plans.

Discharges By Length Of Stay
Number of discharges for each of the ranges of length of stay below.
Line
No.		Time in Facility(1)
Patients
31.Less than 2 weeks36
32.2 weeks to less than 1 month37
33.1 month to less than 3 months30
34.3 months to less than 7 months10
35.7 months to less than 1 year6
36.1 year to less than 2 years2
37.2 years to less than 3 years1
38.3 years to less than 5 years0
39.5 years to less than 7 years0
40.7 years to less than 10 years0
41.10 years or longer0
45.Total122

Hospice Program
Line
No.		(1)
51.Did your facility offer a hospice program during the report period?Yes

Special Programs
Line
No.		(1)
Patients
52.Number of patients diagnosed as having AIDS, ARC, prodromal AIDS or HIV-related diseases and illness (HTLV-III / LAV).0

Line
No.		(1)
53.Does your facility offer a specialized program for Alzheimer's patients?No

Line
No.		(1)
Patients
54.Number of patients who had a primary or secondary diagnosis of Alzheimer's Disease.5
Section 4 - Patient Demographics
Males - Race and Age of Male LTC Patients on December 31.
Line
No.		(1)
< 45		(2)
45-54		(3)
55-64		(4)
65-74		(5)
75-84		(6)
85-94		(7)
95+		(8)
Total
1.White00021328
2.Black00000101
3.Asian / Pac. Islander00000101
4.Native American00000000
5.Other / Unknown00000000
6.Total Males000215210
Females - Race and Age of Female LTC Patients on December 31.
Line
No.		(1)
< 45		(2)
45-54		(3)
55-64		(4)
65-74		(5)
75-84		(6)
85-94		(7)
95+		(8)
Total
11.White0001213622
12.Black00002002
13.Asian / Pac. Islander00000303
14.Native American00000000
15.Other / Unknown00000000
16.Total Females0001416627
Ethnicity of Patients on December 31.
Line
No.		(1)
Male*		(2)
Female**		(3)
Total
21.Hispanic022
22.Non-Hispanic102535
23.Unknown000
25.Total Patients102737
*  Total male patients in line 25, column 1 must be the same as reported in line 6, column 8.
**  Total female patients in line 25, column 2 must be the same as reported in line 16, column 8.
Section 5 - Major Capital Expenditures

Section 127285(3) of the Health and Safety Code requires each facility to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."

Diagnostic and Therapeutic Equipment Acquired During The Report Period
Line
No.		(1)
1.Did your facility acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000? (If 'Yes', fill out lines 2 through 11, as necessary, below.)No

Diagnostic and Therapeutic Equipment Detail
Line
No.
(1)


Description of Equipment
(2)


Value		(3)
Date of Aquisition
MM/DD/YYYY
(4)


Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Building Projects Commenced During Report Period Costing Over $1,000,000

Section 127285(4) of the Health and Safety Code requires each facility to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."
Line
No.		(1)
25.Did your facility commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000? (If 'Yes', fill out lines 26 through 30, as necessary, below.)No

Detail of Capital Expenditures
Line
No.
(1)


Description of Project		(2)
Projected Total Capital Expenditure
(3)

OSHPD Project No.
(if applicable)
26.
27.
28.
29.
30.
General Comments:
Errors and Warnings